Media Release Form

Please enable JavaScript in your browser to complete this form.

Name

First

Last

I do not authorize Bloom U to use any photos and/or video clips (in which I am present) for social media and print media purposes from this event.

Opt Out

Are You a Parent or Guardian?

Guardian Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Checkboxes

I Agree

I grant to, Bloom U, its representatives, and employees the right to take photographs and/or video of me in connection with the event. I authorize, Bloom U, its assigns, and transferees to copyright, use and publish the same in print or electronically. I agree that Bloom U may use such photographs and/or video of me for any lawful purpose, including for example such purposes including publicity, illustration, advertising, and web content. I have read and understand the above.

Date

Behavior & Social

Puberty

CPR

Breastfeeding

Nutrition

Menopause

Media Release Form

Get In Touch

Visit Our Practice