Photo/Image Consent Form

Parental/Guardian Consent Form

I am submitting this parental consent form to both inform you and to request permission for
your childs photo/image and personally identifiable information to be published on my childcare web site and/ or possibly any future program materials.
As you are aware, there are potential dangers associated with the posting of personally
identifiable information on a web site since global access to the Internet does not allow us to
control who may access such information. These dangers have always existed; however, I do want to celebrate
your child and his/her experiences here during our day. The law requires that I ask for your permission to use
information about your child.
Pursuant to law, I will not release any personally identifiable information without prior written
consent from you as parent or guardian. Personally identifiable information includes student
names, photo or image, and locations of field trips. I am very sensitive to this information being out there, and would be
extremely careful never to disclose any exact details that would compromise our safety, to the best of my abilities.
If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in
writing and such rescission will take effect upon receipt by provider Michelle Jensen.
Check one of the following choices:
I/We GRANT permission for my/our childs photo/image and name to be published on Michelle Jensens Childcare
Internet site &/ or any program related materials.

I/We GRANT permission for a photo/image that includes my/our child without any other
personal identifiers to be published on Michelle Jensens Childcare Internet site &/ or any program related materials.
I/We GRANT permission for my/our childs photo/image and all other personal identifiers
listed above to be published Michelle Jensen childcare Internet site&/ or any program related materials.
I/We DO NOT GRANT permission for photo/image that includes my/our child to be
published on Michelle Jensens childcare Internet site &/ or any program related materials.
I/We GRANT permission for my/our childs photo/image to be published on Michelle Jensens Childcare Internet
site &/ or any program related materials, only once we have had a chance to approve in writing each picture of our child
to be included .
I/We GRANT permission for my/our childs photo/image to be published on Michelle Jensens Childcare Internet
site &/ or any program related materials, only if it is nearly impossible to identify the child; cropped in such a way as to
make it impossible to be sure who the picture is of, or taken from such a distance that again it would be near impossible
to tell the identity of the child, and if we notice one on the site we would like taken off, that it be removed in a timely
manner.
Childs Name: (please print) _________________________________
Print name of Parent/Guardian: (print) ______________________________________________
Signature of Parent/Guardian: (sign) _______________________________________________
Relation to Child: ___________________________________________________________
Date: __________________