Using the Media Consent Form:

1.  If possible, photos should not be taken prior to consent.

2.  If taken in a facility, a qualified facility representative may need to sign also.

3.  If taking a picture, ensure there are no other recognizable subjects in background.

4.  If this is going to be used for purposes other than and in addition to DOGTORS, it must be so noted separately on the appropriate lines (magazine article, newspaper submission, use at facility, etc).

5.  Subject / parent must initial after the signature line and on each line of use.

6.  All unused lines must be crossed out before it is signed.

7.  DOGTORS must maintain the original copy on file.  Copies for those involved can be made if requested.

8.  If you have any doubt or questions, call me: 323-0925 or 284-0602.    

MEDIA CONSENT FORM

I hereby grant DOGTORS Animal-Assisted Therapy and /or other media permission

to use my quote and/or photo of me, _____________________________ and/or my 

child(ren) _____________________________________, and any reproductions of same 

may be used by DOGTORS for the purpose of promotion or publicity.

(If DOGTORS is providing any materials to you, such as a copy of an article, etc, please check here ___ and provide mailing address or e-mail information on back of this form).

Date: ______________ Signature: ________________________________Initial_______ 

Date: ______________ Witness: _____________________________________________

Facility permission: (if required)

Name: ______________________________ Title: ______________________________

Date: ______________ Signature: _____________________________

				(Initial)

Photo/Quote to be used in:	______ DOGTORS Website, displays, advertising, etc.
(Initial on appropriate lines)
				______ Other: ______________________________

				______ Other: ______________________________

				______ Other: ______________________________

DOGTORS Animal-Assisted Therapy, LLC
4033 Spfld-Xenia Rd.
Springfield, OH 45506

DOGTORS respects the privacy of all individuals involved. This information will not be for any purposes other than described on this form.