MEDIA CONSENT FORM

ATLANTA PEDIATRIC PARTNERS MEDIA CONSENT FORM

grant permission and give my consent to allow Atlanta Pediatric Partners to use

For the use of the following photograph(s), video(s), or electronic media images on social media platforms, and our company website.

Revocation (check one)

I understand that my authorization below the photograph(s) and/or video(s) may never be revoked.

I understand that I may revoke this authorization at any time by notifying (Please input below) in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images and/or videos will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or achieved.

Parent Signature

Date

Parent Signature

Date

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