Media Release Form | Chester County Connect Care - Pregnancy Care Medical Center located in Coatesville, Kennett Square, and West Chester, PA

Chester County Connect Care (CCCC) is committed to protecting the privacy of our patient’s/supporter information. We must obtain your written consent before we can photograph you and your minor child/children or reveal details about your care/services given for use in publications or promotional materials. Please review the form and be assured your questions are fully answered by a CCCC staff member before signing this form. You are entitled to receive a signed copy. Only you may provide details about your case for promotional purposes, such as advertising, brochures, web pages, publications or news stories. Once stories, photos, audio and videotape enter the public domain, it’s important to understand that other outlets are free to use them. We cannot guarantee that other organizations will not display your publicized images or information. Any publication will not change your relationship with CCCC whether you are a client or a supporter. You may cancel or revoke your authorization at any time by writing to CCCC 1028 East Lincoln Hwy, Coatesville PA; however, if we have already used the information and disclosed it as provided by the authorization, we will not be able to revoke your authorization. Please list specific information you do NOT want disclosed:

Please initial if you want us to use a fictitious name and not your real name:

You agree to the use of photos of you and your minor child/children and the publication of your story, including medical information/ultrasound photographs by CCCC for brochures, publications, websites, promotional material in newspaper, television, radio, magazines and online publications and marketing/advertising by CCCC. You agree to waive any and all rights, claims, actions that you or your baby may have against CCCC arising from the publication and use of your story and photographs. I have read this form, and all of my questions have been answered. BY TYPING OUT MY NAME BELOW, this serves as my e-signature and confirms that I understand and accept all of the above conditions, and approve the use of me and my minor child/children by CCCC. *

Date: *

Name of minor: *

Relationship to minor: *

Email: *

Phone:

Mailing address:

Please email your photos to kirstyn@ccconnectcare.org

Will do!