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Photo Release Form

  1. I do hereby authorize Jefferson County Public Health, and those acting pursuant to its authority to: 

    1.    Record my (and/or my child’s) participation and appearance on video tape, audio tape, film, still photography or any other medium.

    2.    Use my name, likeness, and voice in connection with these recordings.

    3.    Exhibit or distribute such recording in whole or in part without restrictions or limitation for any educational or promotional purpose which Jefferson County Public Health, and those acting pursuant to its authority, deem appropriate.

  2. Name of person or persons photographed or recorded:  

  3. By typing your name above, you agree to authorize Jefferson County Public Health and those acting pursuant to its authority to: 

    1.    Record my (and/or my child’s) participation and appearance on video tape, audio tape, film, still photography or any other medium.

    2.    Use my name, likeness, and voice in connection with these recordings.

    3.    Exhibit or distribute such recording in whole or in part without restrictions or limitation for any educational or promotional purpose which Jefferson County Public Health, and those acting pursuant to its authority, deem appropriate.

  4. Leave This Blank:

  5. This field is not part of the form submission.