Consent for Photography/Videotaping and Use of Original Work

As a participant enrolled in a DYCD-funded program, please be aware that from time to time DYCD and the City of New York, its contracted providers, authorized agents, third-party organizations with which it collaborates, or other government, representatives (collectively, "Authorized Parties") may be present during program activities and special events associated with program services, both at the usual program location and at off-site events. In some cases, they may photograph, videotape, interview or otherwise record participants and their families and friends in these programs. The resulting images, videos, and interviews may be used, with or without the participant's name, in printed and electronic media such as brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs (collectively, "Media").

I hereby authorize and permit the Authorized Parties, without compensation and without further approval, to photograph and/or record my child's image, name, likeness, and the sound of my and my child's voice during DYCD-funded program activities and special events, and I hereby consent to the resulting images, videos and interviews being used, without compensation and without further approval by the Authorized Parties solely for non-profit, non-commercial purposes in any and all Media.*

YesNo

If, in the course of participating in DYCD-funded program activities and special events, any original work such as art, music, choreography, poetry, or prose (collectively, "Original Work") is created by me or my child, I hereby consent to such Original Work being used by the Authorized Parties, without compensation and without further approval, solely for non-profit, non-commercial purposes in any and all Media.*

YesNo

Participant Name*

First NameLast Name

Participant Age*

Participant Email*

example@example.com

Participant Phone Number*

Area CodePhone Number

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

example@example.com

Parent/Guardian Phone Number*

Area CodePhone Number

If participant is 18 and over:*

I acknowledge that I am 18 years of age or older and am authorized to give consent.

If participant is under 18 years old:*

I am the parent or legal guardian of the named minor in this agreement.

Date*

MonthDayYear

Signature*