PHSS Annual Photo Release

PUBLIC HEALTH and SOCIAL SERVICES

David Bayne - Director

Dr. Dimyana Abdelmalek - Health Officer

COUNTY COMMISSIONERS

Carolina Mejia - District One
Gary Edwards - District Two
Tye Menser - District Three

Wayne Fournier - District Four

Emily Clouse - District Five

PHOTO RELEASE FORM

The release below must be signed by the person authorized for signing legal documents.
I give my permission to be photographed and/or to have my child or children herein named, to be photographed with the understanding that the pictures may be used for promotional purposes by Thurston County Specialized Recreation Services.

Participant First Name: *

Participant Last Name: *

Please select all that apply: *

I approve the use of my photo in the Specialized Recreation program guide.

I approve the use of my photo on the Specialized Recreation Services facebook page.

I approve the use of my photo on the Public Health and Social Services website.

I approve the use of my photo on the Specialized Recreation Services website.

I approve the use of my photo on any additional Specialized Recreation Services promotional material.

I DO NOT APPROVE the use of my photo in any publication and/or public website.

Please choose one: *

I am authorized to sign my own legal documents and have reviewed the photo release information.

The person named above is under 18 years of age I am the parent who is authorized to sign legal documents. I have reviewed the photo release information on behalf of my child.

I am the legal guardian authorized to sign legal documents for the person I named above and have reviewed the photo release information on behalf of the participant.

If not the above named participant, have you reviewed this release with the participant named above? *

Yes

Printed Name of Signee: *

Date: * +

Signature: *

clear

412 Lilly Rd. N.E., Olympia, Washington 98506-5132

(360) 867-2679 FAX (833) 499-1806 TDD (360) 867-2603 TDD (800) 658-6384
www.thurstoncountywa.gov/phss