Date

Subject's Name

I,(insert name of parents/guardians) of

(insert name of minor) hereby give the Southern New Jersey Regional Early Intervention Collaborative (SNJREIC) and their legal representatives and assigns the right and permission to publish, my child's photographic image for the specific purpose of publication to their website NJEIS.org In giving my consent, I hereby release and hold harmless NJEIS, Southern New Jersey Regional Early Intervention Collaborative their offices employees, agents and designees from any and all responsibility or liability. I understand that I will receive no compensation, should any photographs of my child be used.

I understand my child's picture and this photo release form will be maintained at SNJREIC. I understand I may change or withdraw this release/consent at any time by contacting SNJREIC in writing to the above address.

This release and child's picture will be valid up to one (1) annual year (April 1,2001 - April 15, 2002). I understand all pictures released to SNJREIC will not be returned and will then be destroyed after the one-year (1) contract. I understand that I may resubmit another picture along with a 2002-2003 updated photo release form.

I understand SNJREIC has full authority as to which pictures they choose to place on their website. SNJREIC is not required nor obligated to use any pictures I submit.

I have read this agreement and understand it.

                                                                           ____________________________________________
Signature of Translator                                                                          
____________________________________________
Name of person in picture                                                                          
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Signature (parent/guardian if minor)

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