Voices of Hope : How To Help : Child & Family Guidance Center of Texoma

Name

First Name *

Last Name *

Phone

Are you:

Client's Name (if different)

Is the client a minor (under 18)

Client's Therapist at CFGC

Type of Participation

Consent for Recording & Use

Record my/my child’s interview (video and/or audio).
Photograph me/my child.
Use these recordings, photographs, and/or written testimonials in CFGC’s promotional, educational, and marketing materials (including but not limited to website, social media, newsletters, printed materials, events, and media).
Edit, reproduce, and distribute these materials without further approval required.
All of the above.

I understand that:

CFGC will handle my story and images respectfully and will not share personal identifying information beyond what I have agreed to.
My participation is voluntary, and I may withdraw consent before the final publication of materials.
Once photos and/or videos are produced and shared, I may request that CFGC discontinue future use of my materials; however, I understand that removal may take time, and previously published content may continue to appear on platforms or materials that are already in circulation.
I will not receive payment for my participation, except in cases where CFGC offers compensation as part of special campaigns.

I agree to all of the above.

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By typing my full name below, I acknowledge that I have read and understood this release and consent form, and I agree to the terms outlined above.

Prefix

First Name *

Last Name *

Date

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