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Media And Storytelling Consent Form

By signing this consent form, you agree to allow Happy Parenting Club or external media outlets to your name, likeness, photograph and/or audio/video footage, without payment, for a story with Happy Parenting Club. Happy Parenting Club reserves the right to use this material for up to five years.

Reason for project:

Personal Information (for administrative use; not for release or publication)

Full name:

Name of parent/ guardian/ substitute decision-maker (if applicable):

Email address:

Telephone number:

I am a:

Expert

Host

Mama KOL/ Content Creator

Other

I grant permission for the following identification to be used in conjunction with my photograph and/or audio/video footage:

First name and last name

First name only

Please do not use my name

I grant permission for Happy Parenting Club to use the information that I shared during interviews and recordings (e.g. diagnosis, care history) in any descriptions or stories published related to this project:

I grant permission for Happy Parenting Club to use the information that I shared during interviews and recordings (e.g. diagnosis, care history) in any descriptions or stories published related to this project:

I do

I do not

Untitled checkboxes field

I grant permission for Happy Parenting Club to contact me for communication purposes.

Signature: (Full name in capital letters)

Date:

Signature of parent/ guardian/ substitute decision-maker if applicable:

Opt-out: To request that Happy Parenting Club discontinue the use of your name, likeness, photograph, audio and video footage in future use, please contact [email protected]