Common use of Media Release Clause in Contracts

Media Release. I give permission for The Arc of McLennan County to have my child appear in any media coverage and use for publicity and fundraising purposes photographs of my child. Signature of Parent or Legal Guardian: __ ___ ___ __ ___ _ Name: (Print Clearly): _ ___ __ Date: ___ __ _ EMERGENCY INFORMATION Child’s Name: Doctor’s Name: Doctor’s Phone Number: Insurance Information: Name of Company: Policy/Group Number: Other: Which hospital do you prefer for your child: (Circle One) Hillcrest Providence Parent Name & Contact Number: Date Signature - Parent/Guardian PARENTAL EMERGENCY MEDICAL CONSENT This form must be presented upon admission for treatment. Child's Full Name: Birth Date: In the event that my child (listed above) may require medical and/or surgical care while I am out of the city or unable to be reached, I hereby give my consent to medical and/or surgical treatment to ___ _ __ Hospital and Doctor __ _ or his/her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.

Media Release. I give permission for The Arc of McLennan County to have my child appear in any media coverage and use for publicity and fundraising purposes photographs of my child. Signature of Parent or Legal Guardian: __ ___ ___ __ ___ _ Name: (Print Clearly): _ ___ __ Date: ___ __ _ EMERGENCY INFORMATION Child’s Name: Doctor’s Name: Doctor’s Phone Number: Insurance Information: Name of Company: Policy/Group Number: Other: Which hospital do you prefer for your child: (Circle One) Hillcrest Providence Parent Name & Contact Number: Date Signature - Parent/Guardian PARENTAL EMERGENCY MEDICAL CONSENT This form must be presented upon admission for treatment. Child's Full Name: Birth Date: In the event that my child (listed above) may require medical and/or surgical care while I am out of the city or unable to be reached, I hereby give my consent to medical and/or surgical treatment to ___ _ ____________________ Hospital and Doctor __ _ or his/her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.. Parents/Guardians/Custodians With Whom The Child Resides: