CHYP Media Release Form
I grant permission to Creative Healing for Youth and Pain (CHYP), hereinafter known as the “Media”, to use my image (photographs and/or video), testimonials, first name (or
alias), age, and diagnosis (optional) for use in Media Publications including:
Social Media (e.g. Facebook, Instagram, Twitter, LinkedIn, YouTube, etc.)
I hereby waive any right to inspect or approve the finished and/or edited photographs, videos, stories, or
electronic matter that may be used in conjunction with them now or in the future, whether that use is
known to me or unknown. I waive any right to royalties or other compensation arising from or related to
the use of the image, video, or other personal identifying information that you provide (including but
not limited to; name, age, diagnoses, story, etc.).
Please note that CHYP may record the conversations and related video so they can be shared with our audience, and those who are not directly involved may still be able to benefit from this “round table discussion.” We discourage you from sharing personal information (last names, phone numbers, social media accounts, addresses, etc.) and sensitive information (medical or clinical advice or diagnoses). However, we may collect and use in Media Publications the following information, as disclosed in the authorization form you signed permitting us to use this information:
• First name (or alias);
• Diagnosis (optional); and
If you have a concern or question about what you or others are sharing, please feel free to reach out to the CHYP team (firstname.lastname@example.org).