KID - Parent Image Release Consent

I, the undersigned, do hereby grant or deny permission to Citipointe Noco to use the image of my child(ren), as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Citipointe Noco website and corresponding social media

Your name *

Email address *

Children's Names

Permissions:

Deny Permission to use my child's image at all.

Limited usage: I want my child’s image used within the Citipointe Noco setting only (not in the larger community). (Ex: bulletin boards, announcements, parent newsletters, etc…)

Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within Citipointe Noco or in the larger community. One example of this could be videos in parent education classes.

Limited usage: I want my child’s image used on printed materials only (no digital or video use).

Unrestricted usage: I give unrestricted use of my child’s image to be used in print, video, and digital media. I agree and understand that these images may be used without further notifications, and that last name’s won’t be used with any media content.

Date Completed

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