Photo Release Form

Visiting Parent's Name

First Name

Last Name

Visiting Parent's Date of Birth

YYYY

----------------------------------------------------------------------------------------

Your Name

Phone Number

(###)

###

####

I am the

Custodia Parent

Visiting Parent

CHILD(REN) INVOLVED IN THIS VISITATION ARRANGEMENT

Child's name, Gender, Date of birth, Age

Consent and Agreement

I, the undersigned, do hereby consent and agree that Unity Visitation Center, Inc. its employees, or agents have the right to take photographs, videotape, or digital recordings of me and/or my children beginning with your first interaction with UVC, before or after the first day of visitation. The use of the above may be used in all media, and/ or exclusively for the purpose of supervised visitations and any activities that arise from services. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that Unity Visitation Center, Inc. is not responsible for any expense or liability incurred as a result of my participation in this recording. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

By adding your initials below, you confirm that all information provided is true and accurate to the best of your knowledge. Your initials serve as your signature, indicating that you agree to the terms, policies, and cost of services of UVC and consent to proceed with supervised visitation services.

Date

YYYY