Photography/Video Internet Authorization
Form
I give permission for photo/video of myself and/or my child, ,
to be used by the media or La Familia Counseling Center, Inc. for publication on www.lafcc.org,
www.Accesslocal.tv, www.facebook.com, www.instagram.com, www.twitter.com and other related
publications and internet sites, including La Familia or program webpage’s. I understand that
confidentiality may be breached due to recognition of myself and/ or my child(ren).
I, the undersigned, am the person, parent, and/or legal guardian of the person noted on this document,
and herby fully release and discharge the La Familia Counseling Center, Inc., its employees, agents,
volunteers, and all other persons in association with La Familia Counseling Center, Inc., from any and all
liability arising out of in connection with the above described independent activity and all liabilities
associated with any and all claims to such activity that may be filed on behalf of or for the above-named
person. For the purpose of this release, ‘liability’ means all claims, demands, losses, causes, or action,
suits or judgments of any every kind that arise as result of the above described activity and resulting
from any causes other than La Familia Counseling Center, Inc.’s gross negligence.