Release Form for Media Recording

I hereby grant permission for Space Between and the University of Washington Center for Child and Family Well Being (the “Organizations”), its employees or agents to take photographs, videotape, or digital recordings of the above-named person, and to make use of such images and recordings as the Organizations deem appropriate, including but not limited to posting on the website of the Organizations.

I also give permission for the Organizations to use the first name only of the above-named person in connection with such images and recordings, but I understand that images and recordings may be used without identifying the person or any other subjects by name.

I understand and agree, on behalf of myself and the above-named person, that neither I nor the above-named person will receive any financial or other remuneration for the use of any images or recordings, either for initial or subsequent use, transmission or playback. I also understand that the Organizations are not responsible for any expense or liability incurred as a result of my participation in the photograph or recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I have read and understand the foregoing statements and am competent to execute this agreement.

I hereby grant permission for Space Between and the University of Washington Center for Child and Family Well Being (the “Organizations”), its employees or agents to take photographs, videotape, or digital recordings of the above-named person, and to make use of such images and recordings as the Organizations deem appropriate, including but not limited to posting on the website of the Organizations.

I also give permission for the Organizations to use the first name only of the above-named person in connection with such images and recordings, but I understand that images and recordings may be used without identifying the person or any other subjects by name.

I understand and agree that I will not receive any financial or other remuneration for the use of any images or recordings, either for initial or subsequent use, transmission or playback. I also understand that the Organizations are not responsible for any expense or liability incurred as a result of my participation in the photograph or recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I have read and understand the foregoing statements and am competent to execute this agreement.

I hereby grant permission for Space Between and the University of Washington Center for Child and Family Well Being (the “Organizations”), its employees or agents to take photographs, videotape, or digital recordings of the above-named person, and to make use of such images and recordings as the Organizations deem appropriate, including but not limited to posting on the website of the Organizations.

I also give permission for the Organizations to use the first name only of the above-named person in connection with such images and recordings, but I understand that images and recordings may be used without identifying the person or any other subjects by name.

I understand and agree, on behalf of myself and the above-named person, that neither I nor the above-named person will receive any financial or other remuneration for the use of any images or recordings, either for initial or subsequent use, transmission or playback. I also understand that the Organizations are not responsible for any expense or liability incurred as a result of my participation in the photograph or recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I have read and understand the foregoing statements and am competent to execute this agreement.

I hereby grant permission for Space Between and the University of Washington Center for Child and Family Well Being (the “Organizations”), its employees or agents to take photographs, videotape, or digital recordings of the above-named person, and to make use of such images and recordings as the Organizations deem appropriate, including but not limited to posting on the website of the Organizations.

I also give permission for the Organizations to use the first name only of the above-named person in connection with such images and recordings, but I understand that images and recordings may be used without identifying the person or any other subjects by name.

I understand and agree that I will not receive any financial or other remuneration for the use of any images or recordings, either for initial or subsequent use, transmission or playback. I also understand that the Organizations are not responsible for any expense or liability incurred as a result of my participation in the photograph or recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I have read and understand the foregoing statements and am competent to execute this agreement.