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Photograph and Video Release Form

Date__________________

I, _______________________________, (Name Please Print) do hereby grant permission to the Statewide Health Improvement Program of Cottonwood, Jackson, Faribault, Martin & Watonwan Counties/Minnesota Department of Health (MDH) to videotape or photograph me, and to use the images thus obtained a part or in connection with the production of MDH publications, social media (Facebook), website and blogs and audio-visual presentations. I understand that these materials will be used for the purpose of informing and educating the public about SHIP programs and activities. I further understand that these photographic or video images may be distributed or displayed to members of the general public in connection with SHIP informational programs and activities. I also understand that refusal to grant such permission would not and cannot result in the loss of any rights to which I am otherwise entitled by law.

_________________________________ (Witness)

_________________________________ (Signature)

_________________________________ (Parent or Guardian)