(   ) I waive any right to inspect or approve the finished product, including written copy, wherein my child’s likeness appears.

(   ) Realizing that no pertinent information regarding my child will be included or released in regards to any likeness used, I hereby irrevocably give permission to Country Fun Child Care (inclusive of provider and staff) to publish likenesses of my child, involved in activities while in care at Country Fun Child Care in any of the following venues for lawful purpose. Pertinent information includes, but is not limited to: child’s last name, age, address, guardian’s name, specific physical disabilities, and/or identification of activity site.

  • Websites administered by Country Fun Child Care and social media sites such as, but not limited to, Facebook.
  • For the accounts set up that host shared videos (such as vimeo). These videos may also be embedded in the above website and social media site posts.
  • On any individual private/code activated accounts set-up for a child as part of documentation of their learning. Only the child’s parents/legal guardians may pass out the private password/code to individuals that the child’s parents/legal guardians wish to have viewing rights.
  • To be hung within Country Fun Child Care’s premises where viewable by the public that enters the program space.
  • Promotional materials for Country Fun Child Care.
  • For use on assignments/observations as needed for such as: educational training classes (inclusive of Provider and Staff) is taking, facilitating or presenting; maintaining Star level in QRIS.

(     ) I do not give Country Fun Child Care permission to use, publish and/or re-publish my child’s likeness.

(   ) I understand that this Release to Use Likeness does not pertain to the likeness and information used as part of the emergency preparedness plan developed by Country Fun Child Care.

Child’s Name:             


I hereby hold harmless and release and forever discharge Country Fun Child Care and all of its agents, employees and representatives, and their successors, from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Legal Guardian’s signature:                                  Date: 

Print Name: