2. Washington County Photo and Video Authorization 

4. Acknowledgement

   I authorize Washington County and/or its authorized representatives to take and release my photo and video image(s), and/or my child/children's photo and video image(s).

   I grant Washington County to use, edit, broadcast, and/or publish said images in any media format, including but not limited to: print, video, electronic, website, social media and television. 

   Potential use of said images may include, but are not limited to, educational or promotional materials by Washington County.

   I understand the images may be duplicated and/or distributed by others who are or may not be subject to this release and authorization and are outside the control or supervision of Washington County. 

   • I waive my rights to inspect any photo and/or video images of me and/or my child/children.
   • I agree that I shall receive no  compensation of any kind for use of said images.
   • I understand that I am under no obligation to give consent, but I give my consent voluntarily. 
   • I also understand that I cannot later revoke this consent for any reason. 
6. Event or Description of Photo and Video*
7. Date*
   Date
9. Names of Identifiable Person(s)*
11. Is Identifiable Person(s) Age 18 or Under?*

    1. Yes
    2. No
12. Parent Name(s) of Minor Person(s)*
14. Phone Number
15. Email Address
17. Address1
18. Address2
20. City
21. State
22. Zip
24. Signature*

    1. By Checking this Box, I confirm that I have read, agree and consent to the statements in their authorization form.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field