Media permissions Authorization for recording of images & audio for use by Catherine Burns, MamaBebe LLC. I hereby give to Catherine Burns, MamaBebe LLC, permission to record my (our) image(s), voice(s) and story. I release to Catherine Burns, MamaBebe LLC, all rights to these images, likeness, voice(s), and story as recorded by video, photography, audio, interview or written record. I understand that these recorded images, audio or written stories may be used or published by MamaBebe LLC in curriculum, handouts, brochures, website, social media or used in a venue, such as an educational workshop, presentation or conference. I hereby release any and all claims against Catherine Burns, MamaBebe LLC, arising in connection with use of my (our) images, likeness, audio recording or written story. I particularly waive any claims to compensation. I acknowledge this release as firm and final, and understand that Catherine Burns, MamaBebe LLC, may proceed in reliance of our agreement. For her part, Catherine Burns, MamaBebe LLC, commits to honor your trust in sharing your image(s), any voice recordings and/or written stories by presenting you respectfully.Persons who will be in video, photo and/or audio recording session(s)*Please check all boxes to anyone who is participating in the recording session, including yourself, your child(ren), family members and/or friends. Myself, who will digitally sign below My partner, who also authorizes recording & use of images and/or audio My child or children, whom I authorize to be in the recording Other family members or friends who have authorized recording & use of their image and/or voice My name* First Last Partner's name First Last Child who is receiving therapy First Last If another child or children are present, you give permission for this child/these children to be in the video/photo/audio session.Please include names of other adults who are below. These adults have given permission to be in the video/photo/audio session. Email*Please provide your contact information. Phone*Partner's EmailPlease provide your partner's contact information. Does your child breastfeed?* Yes No Breastfeeding - Exceptions to the Release AgreementIf you wish to exclude images that expose breast areas, you can check any that apply:Exclude when nipple is visible.Exclude when breast is visible (general skin area, but nipple not visible.)You have many options of how your name may be listed (identified) in print publication. Here are some examples for parents and for children. OPTIONS & examples in naming for the ADULT to whom quote would be attributed: Alexa Tully (full name of adult), A Tully, Alexa T, Alexa, Mama A, Mama T, or any variation that you make up. I may include mama (or mother or mom) to indicate to whom a quote should be attribute. OPTIONS & examples in naming for the CHILD, who is usually mentioned in a quote: First name - Examples: Seamus (name of baby or child), Baby S, Baby T, Baby S.T., or any variation that you make up. OPTIONS & examples for naming a PARTNER, if present or mentioned in quote: Usually first name reference only: My partner (husband, wife), George Smith (First name in full) George S, my husband G (or partner, wife), Dad G or Papa G, or any variation that you make up. ET for other people mentioned in a print quote How do you want your name identified? Please state below:* How does your want your partner's name identified? Please state below: How do you want your child's name identified? Please state below: How do you want names of any other people in the photo, video or story identified?By my signature below, I freely agree to this Media Release Authorization, as described above, for myself and my child(ren). Any other adults present in the session have agreed that they either give permissions to be recorded, or will stay out of the recording frame.Signature* Date* MM slash DD slash YYYY CAPTCHAThank you for sharing your story with other families. CommentsThis field is for validation purposes and should be left unchanged.
