Waiver Form 
The United States Department of Health and Human Services and the Administration on  Children and Families, has my permission to use my photograph, likeness, artwork,  profile and/or story in all forms of media and all manners, including publications, web  pages, video and other promotional materials. I understand the circulation of the  materials could be worldwide and that there will be no compensation to me for this use.  I waive any right to inspect or approve the finished product, including written copy that  may be created in connection therewith. 
Signature Date Parent Signature (If under 18) Date 
Print Name Phone Number   (optional)   
Email Address: 
Photo/Video Date and Location: 
Description of activities or programs in photo: 
For internal use only: File number: ____________________ Date: ____________________