RELEASE AND AUTHORIZATION FORM FOR MINORS

PUBLICATION/WEB SITE/PHOTO/VIDEO/INTERVIEW

Question Title

* 1. Name of Minor Child

Question Title

* 2. Name of Parent or Legal Guardian

Question Title

* 3. Date

Question Title

* 4. I acknowledge that my child listed is considered a minor under New York State Law, and therefore, a parent or legal guardian’s signature is required for release of my child’s name and identity in publications in various mediums. I hereby consent to and grant Hudson Headwaters Health Network permission to include and identify my child in any publication, photograph and audio or visual recordings of any kind and in whatever medium it may use for educational, marketing, publicity, and/or fundraising purposes. If my child is interviewed by staff from Hudson Headwaters or any affiliate programs, I also give permission to use my child’s name, story, and any of my child’s direct quotes for education, marketing, publicity and/or fund raising purposes in any medium. I understand and agree that Hudson Headwaters retains all rights to the photographs, moving images, sound recordings, and other media, and that I, or my child, will not be compensated for any Hudson Headwaters use of same. I hereby waive any right I, or my child, may have to inspect or approve media that contains my child’s name, image, sound recordings, story, and/or biographical data.

Question Title

* 5. I understand and acknowledge that Hudson Headwaters and its affiliate programs will rely on this Release and Authorization, and I hereby agree not to assert any claim of any nature against Hudson Headwaters, its employees and agents, and/or affiliate programs relating to the exercise of the permissions granted by this Release and Authorization. I understand and agree the materials developed during this period may be utilized indefinitely. I am signing this Release and Authorization voluntarily on behalf of my child, and understand that provision of services to me and my child by Hudson Headwaters and/or its affiliate programs is not conditioned on whether or not I sign it. I understand that I may revoke this Release and Authorization at any time, in writing, but that a revocation will not impact any use or disclosure made prior to the date revocation is received.

T