EASTER SEAL CAMP KYSOC
CARDINAL HILL HEALTHCARE SYSTEM
Authorization for Videotaping/Photographing For the Camper Program
The undersigned grants permission for the videotaping and/or photographing of the following:
____________________________________________________________
Identifying information such as name, address, age, diagnosis and parents (in the case of a minor) may be included:
The videotapes and/or photographs will be used by the staff specifically for:
___________________________________________________________
No other use of the videotapes and/or photographs shall be allowed.
Specific dates video/photographs shall be used:
From_________________ To_____________
After this date, new client authorization will be required for use of videos and/or photos.
_______________________ _____________________________
Today’s Date Reauthorization Date (if applicable)
_______________________________________________________
Name of Camper
_______________________________________________________
Signature of Camper or Legal Guardian/Employer
_________________________________________________________________
Address
__________________ _______________________________________________
Phone Email ________________________________________________________________________
Relationship
________________________________________________________________________
Witness
IF THE SUBJECT IS A MINOR, SIGNED AUTHORIZATION MUST BE OBTAINED FROM THE PARENT/LEGAL GUARDIAN.
The videotape(s) and/or photograph(s) are the property of Cardinal Hill Healthcare System.
_______________________ _______________________________________________
Phone E-Mail
________________________________________________________________________
Relationship
________________________________________________________________________
Witness
IF THE SUBJECT IS A MINOR, SIGNED AUTHORIZATION MUST BE OBTAINED FROM THE PARENT/LEGAL GUARDIAN.
The videotape(s) and/or photograph(s) are the property of Cardinal Hill Healthcare System.