Signal Centers Media Release Form

Media Release Form

Signal Centers, Inc.
Signal Centers and its affiliated programs—such as Child Care WAGE$® Tennessee and the Child Care Resource & Referral (CCR&R) Network—frequently participate in community engagement, training, and educational outreach efforts.

During these activities, photographs, video recordings, and audio may be captured. These materials may be used in a variety of formats to help showcase and promote the mission and impact of our work.

By signing below, I acknowledge and agree to the following:
- I grant Signal Centers permission to use the name(s), image(s), video, and/or voice recordings of myself and any household members under the age of 18 listed below.
- I understand these materials may be used for promotional, educational, and outreach purposes.
- I understand I will not receive any financial compensation for the use of these materials.
- I understand that I may request to revoke consent at any time by contacting Signal Centers at info@signalcenters.org.
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Participant Information (Include all persons being considered for media use)*
Consent Options (Please Select One)*

Yes, I give permission for Signal Centers, Inc. to use names, photographs, video, and/or audio of myself and/or the individuals listed above.No, I do NOT give permission for Signal Centers, Inc. to use names, photographs, video, and/or audio of myself and/or the individuals listed above.
I confirm that I am 18 years or older and authorized to provide consent for myself and/or minors listed above.
Do you utilize a screen reader?*

YesNo
If you use a screen reader and are the parent/guardian of the applicant, please type your name in the fields below as your signature. Otherwise, leave blank and complete the Signature section below.

First NameLast Name
Signature

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