Consent to be photographed or videotaped

Consent to be photographed or videotaped form

Fill out the form below to provide consent to be photographed or videotaped for use in advertising, online or social media purposes.

Father, mother or guardian name

Address

Are you the father, mother or guardian?

Father Mother Guardian

Minor's name

I have read the above and do consent to all the provisions of such agreement on behalf of the minor listed above.

Yes No

Electronic signature

I do hereby release Roper St. Francis Healthcare, its successors, assigns, and all persons working under the organization’s authority from any liability whatsoever that might occur as a result of the taking, use, or publication of my child's photograph(s) and/or video.

Contact us

There are multiple ways that you can reach out to us. Find a point of contact on our contact information page or find a media contact through our Corporate Communications Department.

Find a point of contact Find a media contact

Consent to be photographed or videotaped form

Consent to be photographed/videotaped - additional consent needed for minors

Contact us