Art Therapy Group Participation Photo Use Consent/Release

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby authorize the Lowcountry Autism Foundation (LAF), Alyssa L. Millard, MAAT, ATR-BC, or any employee or contracted service provider of LAF permission to use my or my  child’s (listed below) likeness and/or an image of my or my child’s art work in a photograph in any and all of her publications, including but not limited to all of LAF’s printed and digital publications as well as in the pursuit of educationally based studies, presentations and publications. I understand and agree that any photograph using my or my child’s likeness or the image of an art piece that my child created will become property of LAF and will not be returned.

I acknowledge that my child’s participation, with Alyssa L. Millard, MAAT, ATR-BC, or any employee or contracted service provider of LAF, and with any volunteers or representatives of any of the aforementioned ,is voluntary, and neither I or my child will receive any financial compensation.

I hereby authorize LAF, Alyssa L. Millard, MAAT, ATR-BC, or any employee or contracted service provider of LAF, to edit, alter, copy, exhibit, publish or distribute this photo for purposes of furthering research and education about the art therapy process as well as for publicizing LAF programs or for any other related, lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my or my child’s likeness or an image of my or my child’s art work appears. 

Additionally ,I waive any right to royalties or other compensation arising or related to the use of the photograph(s).I hereby hold harmless and release forever, discharge LAF, Alyssa L. Millard, MAAT, ATR-BC, or any employee or contracted service provider of LAF, volunteers or representatives from all claims, demands, and causes of action which I and my child may, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of authorization.

I understand that this release is valid until rescinded by me in writing. If this release is rescinded, I understand that all use of images of my or my child’s likeness or of my or my child’s art product will be removed from all publications and creations moving forward, but cannot be removed from documents already in print. The image will be removed from all electronic media moving forward from the written document date rescinding my permission. I will not hold LAF, Alyssa L. Millard, MAAT, ATR-BC,  or any employee or contracted service provider of LAF, volunteers or representatives responsible for anything during the time that this release while it is and was active or after.

Furthermore, I understand that by not signing this release or in rescinding this release later, and not giving my permission to use my or my child’s likeness or an image of my or my child’s art work, it will in no way effect the quality of the art therapy treatment that I or my child are to receive.

Child's Name *
Child's Name
Parent/Guardian Name *
Parent/Guardian Name
Electronic Signature *
Electronic Signature
Parent/Guardian Full Name
Electronic Signature *