Permission for Release of Name and Image for Media Publication
Note: Please complete this form and click on submit at the bottom of this page. Then click on the next link to reach the signature page and sign your name.

Printable version available at:

I hereby grant the display of a photograph of my son/daughter/ward and the release of her/his name for media publication in regards to the Ontario CEC Annual Provincial Special Education Conference; this may include the Ontario CEC website, Facebook page, printed conference materials and/or a press release.

The photo should be sent by email or text as a (jpeg file) attachment.

Email or text a photograph to:
Ana Lia Pauchulo, Awards Chair

*** If 18+ and capable of giving consent, award recipient may sign for self.
Sign in to Google to save your progress. Learn more
Email *
Print Child's Name: *
Parent/Guardian's Name *
I consent to the above agreement *
Date *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy