Photo Release Form

Visiting Pet Teams of South Mississippi- Pet Therapy Group

Authorization for Photographing, Videotaping or Recording

I do hereby authorize _______________________________________________ (Volunteer's name)

member of Visiting Pet Teams of South Mississippi to use ___________________________________________________________________ (specified photographs, videotapes or recordings) for general use of Visiting Pet Teams of South Mississippi publications, including addition to website and brochure.

Print name of person/ people in the photograph _______________________________________________________________________________

This authorization is voluntary and I expect that Visiting Pet Teams of South Mississippi will not share the images or authorize use of the images to another party without my consent.

Signature __________________________________________________Date___________________

Name and contact information of party in the picture or recording:

____________________________________________________________________________

Date received:

This form can be printed and given to the facility. Form must be returned to VPTSM before picture will be used.