Child Photo / Video Waiver

I grant consent for my child, ___________________________, to have his or her picture taken or to be filmed with a New York State Senator or group of Senators. 

I authorize any Senator(s) and/or the New York State Senate to publish such picture or video footage on any such Senator’s official Senate website and/or any official electronic or paper publication of such Senator or the Senate. This consent is not revocable. 

This consent shall not allow any further publication or broadcast of such picture or video footage by any other party, or in any other location or format (e.g. campaign materials, social networking websites, etc.) without my advance written authorization. 

___________________________

Signature of Parent/Guardian 

___________________________

Printed Name 

___________________________

Date 

*Please return signed waivers to the appropriate Senator at his or her office. Visit http://nysenate.gov/contact for contact information.

** To view this document in Spanish and Chinese, download this version of the PDF.