Form Center

2. In an attempt to better inform the community about public health events and services, Clay County Public Health Center publishes names and images of community members through printed and electronic materials. The health center may also provide information and images to the news media. 

   To protect adults and children from unauthorized publicity, the health center is seeking permission prior to distributing any such information or imagery. The release will remain in effect as long as you or your child volunteers, is a student or intern at CCPHC, or until you change your permission in writing.

4. Name of person authorizing*

   1. I GIVE PERMISSION for the name and likeness (photographic, video and electronic images) of myself and/or my child to be used in print or electronically published materials (including but not limited to television, internet, and cable) as distributed by Clay County Public Health Center and/or news media.
   2. I DO NOT GIVE PERMISSION for the Clay County Public Health Center to use the name and likeness of myself and/or my child in print and electronic materials as described above.
6. Name of adult authorizing*
8. Do you wish to provide permission for a child/children (must be parent or legal guardian)*

   1. Yes
   2. No
10. Names of child(ren), if applicable
12. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
14. Signature of Authorizing Volunteer/Intern/Client or Parent/Legal Guardian*
16. Today's Date*
    Today's Date
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field