Baby Gallery Submission

Thank you for being part of the NCFMC Baby Brag Wall! Please fill out the release form below and we’ll share that sweet baby face right here!

Photography Release for Minor Child or Children for use by Northern California Fertility Medical Center

I hereby authorize Northern California Fertility Medical Center, to publish photographs or images provided by myself of the child/children listed below for use in the Northern California Fertility Medical Center’s print, online and video-based marketing materials, as well as other Company publications.

I hereby release and hold harmless Northern California Fertility Medical Center from any reasonable expectation of privacy or confidentiality for myself and for the minor child/children listed below associated with the images specified. Further, I attest that I am the parent or legal guardian of the child/children listed below and that I have full authority to consent and authorize Northern California Fertility Medical Center to use their likenesses and names.

I further acknowledge that participation is voluntary and that neither I, the minor child/children will receive financial compensation of any type associated with the taking or publication of these photographs or participation in Northern California Fertility Medical Center marketing materials or other company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release Northern California Fertility Medical Center, its contractors, its employees and any third parties involved in the creation or publication of Northern California Fertility Medical Center publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor child/children listed below.

Authorization

Date *

First Name *

Last Name *

Email Address *

Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

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Name, Age and Date of Birth of Minor Child/Children:

Child's Name

Date of Birth

Photo Upload

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Accepted file types: jpg, png, jpeg, heic

Child's Name

Date of Birth

Photo Upload

No file chosen

Accepted file types: jpg, png, jpeg, heic

Child's Name

Date of Birth

Photo Upload

No file chosen

Accepted file types: jpg, png, jpeg, heic

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Baby Gallery Submission

Photography Release for Minor Child or Children for use by Northern California Fertility Medical Center

Authorization

Name, Age and Date of Birth of Minor Child/Children:

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