Media Consent & Release Form
First Image/Pregnancy Resource Centers
Client Name
First Name
Last Name
Pregnancy Resource Center Location
SE Portland
Gresham
Beaverton
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of
Child(s) name in photo (optional)
First Name
Last Name
Date photo taken
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
example@example.com
Authorization, Release, and Consent
Can we use your name?
First name
Use fictitious name(s) only
Read the options below and check box if agreed:
I hereby authorize and release First Image/Pregnancy Resource Centers (PRC) to reproduce, circulate, and/or use my likeness and/or my child’s likeness in theform of photograph(s), video's, stories, etc., for the use of encouragement,educational, promotional and/or fund-raising in connection with our non-profitorganization. This may include sharing via our blog, social media, email, direct mail, printed materials and/or other various formats and communications platforms.
I understand that my action is voluntary, and is in no way necessary, in order for me to receive or continue to receive services from the center.
I am over (18) years of age and I have full legal capacity to grant this consent and release, and have read and understood the above consent and release prior to its execution. ***If I am under (18) years of age, my parent or guardian attests that he or she has read and understands the above consent and release prior to execution and agrees to such release.
Signature
Date Signed
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Month
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Day
Year
Date
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