Media and Photo Release

First and last name of Individual Being Served by Clark DD

Parent or Guardian Name (If applicable)

Your Email

Your Phone

I authorize Developmental Disabilities of Clark County (DDCC) to use the individual above's name, photo, video, comments or other media for the purpose of publicizing accomplishments and achievements in newsletters, brochures, websites, social media, and any other public relations activities for DDCC. This may include any activities in which s/he participates, including but not limited to Special Olympics, public or private employment, day services, and special events. I authorize DDCC to edit, copy, exhibit, publish and distribute this information without prior notification and without payment or any other consideration. I understand and agree that these materials are the property of DDCC. I waive the right to inspect or approve the finished product including written or electronic copy. Permission granted will allow the use of the media permanently unless otherwise slated or DDCC receives a written request to stop its use.

Do you consent to the above terms? Please select Yes No (story/photo cannot be used)

Type your full name below to sign as the person legally responsible

Optional Photo Upload (up to 4 files)

Accepted file types: jpg, gif, avi, mp4, mpeg. Max. file size: 2 GB per file.