Media Authorization Form
AUTHORIZATION FOR USE OF MEDIA
Encompass relies on candid images of its program participants to accurately share what we do with the public for fundraising,
marketing, and educational efforts. Photos and videos of actual program participants are powerful tools for showing how
Encompass affects real people in our community. We thank you for sharing your story with us!
By signing below, I understand that:
- I give Encompass permission to edit, alter, copy, exhibit, publish, or distribute media of my child and of myself obtained during the course of official Encompass activities.
- I acknowledge that such media may be used without additional notice after signing this form.
- This authorization shall not expire unless I otherwise cancel the authorization and accordingly inform Encompass of such cancellation.
- I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. I understand that to revoke my authorization, I must do so by submitting my written revocation to Encompass, 9050 384th Ave. SE, Snoqualmie, WA 98065.
- Encompass will not sell pictures or video of my child but may utilize them for fundraising and/or marketing purposes including, but not limited to, brochures, websites, promotional videos, and social media posts.
- Any disclosure of information carries with it the potential for an unauthorized re-disclosure and may not be protected by federal or state confidentiality laws.
- I acknowledge that I am not entitled to compensation for the use of such media.
- I am not required to sign this authorization to receive services from Encompass, nor will Encompass condition my receipt of services on whether I execute this authorization.
- This authorization does not apply to information and/or activities protected by the Health Insurance Portability and Accountability Act (HIPAA), which will never be shared under any circumstances.
I hereby hold harmless and release and forever discharge Encompass from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of reliance on this authorization.