All For Kids Pediatric Clinic is in the process of designing a web site.  We would like to use pictures of your children in the web site.  We are looking for action shots of things your child or children are involved in.  If you would like to submit your child’s photo, we will need a high quality photo and a release allowing us to use your child’s picture on our website. We have 3 ways of doing this: 

  1. Return the photo on a CD and the release form to All For Kids
  2.  Copy and paste the release on your email – state you consent to the release and email to us with a picture to photos@afkpeds.org
  3. Or email a picture to photos@afkpeds.org and return a release in person or by mail to All For Kids

 Thanks for your help!  We look forward to seeing all of your children on the web site! 

Consent to use Pictures 

  •  I authorize All For Kids Pediatric Clinic and associates to use pictures of my child I have submitted for use in All For Kids web site.
  • Details of the photographing/ web site have been explained to me in terms I understand.
  • I also understand that the photos become the property of All For Kids Pediatric Clinic.
  • I agree and authorize use of the photos in advertisements of All For Kids Pedicatric Clinic.
  •  I am aware that my name and my child’s name and identity will not be disclosed.
  •  I agree and authorize All For Kids Pediatric Clinic to place me and/or my child’s photo on their professional web site.
  •  I certify that I have read and understand this agreement.

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 Print Patient /Child’sName                                       

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  Parent or Legal Representative              Date