CATHOLIC CHARITIES DIOCESE OF METUCHEN CONNECTIONS PROGRAM PUBLIC RELATIONS CONSENT FORM TO PHOTOGRAPH CHILD/YOUTH This consent is for

r the client identified and named as ____________________________. Client Address: __________________________________________________________. Client Telephone Number: _________________________________________________. As the above named client, or on behalf of the above named client, I do hereby authorize Catholic Charities for program purposes only to: ______ Photograph or video the above named client.

The following stipulations checked are to be applied to this consent: I do _____ or do not _____ consent to permit Catholic Charities and/or members of the program to make photographs or videos and to reproduce such pictures for general distribution for program, mentor or client use. I understand that I can revoke this consent at any time or for any reason except to the extent that action has already been taken in release thereon. I realize that in consenting to the activities specified above, I hereby release and discharge Catholic Charities, its agents and employees from all liability, claims or demands, in law or in equity that I might have against any of them by reason of such use and subsequent use thereof. I am a) _____ the above client or b) _____ the parent/legal guardian of the above named client. I have read this release or it has been read to me. I understand what is asked and willing consent to participation in the activities specified by the above named client. I further verify that all information on this form was completed at the time of my signature. Signature of client: ___________________________________ (To be signed by client if client is 14 years of age or older.) Signature of Parent/ Guardian: ___________________________ Date: _____________ Date: _____________

Staff Signature: _______________________________________ Date:_____________ Jeanette Nadonley/ Rosi Pena