2. 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.

4. Date
   Date
6. Photo Location

8. Name of person or persons photographed or recorded:  

10. First Name of Adult*
11. Last Name of Adult*
13. First Name of Child, if Applicable
14. Last Name of Child, if Applicable
16. Address
18. City
19. State
20. Zip Code
22. Phone Number*
24. E-Signature*

    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.

26. Parent/Guardian E-Signature (if under 18)
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field