I,

_______________________________________________________________________

(parent’s or guardian’s name)

give permission for

_______________________________________________________________________

(name of child care provider or facility)

to photograph my child,

______________________________________________________________________

(child’s name)

for the following purposes:

Type of Use:	(Please check one)
	Grant Permission	Decline Permission
Still Photographs:
Display in provider’s personal scrapbook
Give photographs to current clients
Display in facility’s scrapbook or bulletin boards, shown to current and/or prospective clients
Display still photos on facility’s website *
Use still photos in promotional materials
Videos:
Give video to current parents
Display video on facility website
Use videos in promotional materials
Other (please list):

* only first names and possibly last initials (in the event of two or more children with the same first name) will be displayed on the facility website.

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize one or more of the above uses. I agree that this form will remain in effect during the term of my child’s enrollment.

Signed:

_______________________________________________________________________(parent or guardian signature, and date)