Form DCF-2260 "Authorization to Release Information, Photo and/Or Video Images" - Connecticut

What Is Form DCF-2260?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2260 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2260 "Authorization to Release Information, Photo and/Or Video Images" - Connecticut

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Connecticut Department of Children and Families
AUTHORIZATION TO RELEASE INFORMATION, PHOTO and/or VIDEO IMAGES
DCF-2260
11/16 (New)
Page 1 of 1
I, _______________________________________________________________________ (insert name), hereby agree to the release of
information
photos,
videos, or
all of these media, subject to conditions listed below by the Department for use in the public arena, in accordance with the
needs of the agency, including the internet and in the release of information to other media platforms operated by individuals outside the Department. I
also understand that when information is posted on the
Department websites that outside organizations may access it and use the information independently.
This release applies to and covers the uses listed, but are not limited to: photographic, audio or video recordings which may be used for the following purposes:
presentations, brochures, educational courses, informational presentations, on-line educational courses, educational videos and all DCF social media platforms,
statements or
I understand that I do not have to agree to this release of information, but do so knowingly subject to the following restrictions (check the applicable
"not Applicable"); I hereby release, discharge, and covenant not to sue the State of Connecticut, Department of Children and Families from any claims
arising from the use of the Performance including, but not limited to, any claims that CT DCF has defamed me, invaded my privacy, or infringed my moral
rights, rights of publicity or copyright. I hereby waive the right to inspect or approve any uses of the Performance.
I further agree that this agreement shall be governed by the laws of the State of Connecticut without regard to its principles of conflicts of laws, and shall
be binding on me, my heirs, assigns, licensees, and legal representatives. If any term of this agreement is determined to illegal, unenforceable, or in
conflict with any law, the validity of the remaining portions will not be affected thereby.
I do
I do NOT
Agree to have my full first and last name released
I do
I do NOT
Not Applicable
Agree to have ONLY my first name released
I do
I do NOT
Agree to have my child(ren)'s full first name and last name released
I do
I do NOT
Not Applicable
Agree to have ONLY my child(ren)'s first name released
I do
I do NOT
Agree to have the town/city of my family's residence released.
I do
I do NOT
Agree to allow my face to be shown in pictures or video to be released
I do
I do NOT
Agree to allow my child(ren)'s face(s) to be shown in pictures or video to be released
I do
I do NOT
Agree to the release of information about me and my family but without any identifying information released.
I understand that authorizing the use or disclosure of this information is voluntary, and I do not need to sign this form to receive services. I understand
that the confidentiality of my information is protected by federal and state confidentiality laws. I grant to the State of Connecticut, Department of Children
and Families (“CT DCF”) the right to copy, reproduce, photograph, distribute, transmit, broadcast, exhibit, transcribe, digitize, display, copyright, license,
transfer, reproduce, translate, modify, edit or otherwise use throughout the world in all media now existing and hereinafter developed for educational,
promotional or other purposes that support CT DCF’s mission, in accordance with my above selected statements. My authorization will remain in effect in
perpetuity except that I retain the right to revoke this release at any time. I understand that these rights are granted to CT DCF and may be used in whole
or in part in any media without compensation.
I have read and understood this agreement, and I am over the age of 18. I represent and warrant that I have the legal right and power to grant CT DCF
the rights granted above. Accepted and agreed to by:
First and Last Name (Print)
Signature
Date
Name of Parent or Guardian, if child is under 18
Signature of Parent or Guardian, if child is under 18
Date
Address
City, State
Zip
Name of Photographer
Signature of Photographer
Date
STATE OF CONNECTICUT
www.ct.gov/dcf
This completed and signed form must be returned to the DCF Legal Division,
along with a copy of the information, photo, video or all three attached
Connecticut Department of Children and Families
AUTHORIZATION TO RELEASE INFORMATION, PHOTO and/or VIDEO IMAGES
DCF-2260
11/16 (New)
Page 1 of 1
I, _______________________________________________________________________ (insert name), hereby agree to the release of
information
photos,
videos, or
all of these media, subject to conditions listed below by the Department for use in the public arena, in accordance with the
needs of the agency, including the internet and in the release of information to other media platforms operated by individuals outside the Department. I
also understand that when information is posted on the
Department websites that outside organizations may access it and use the information independently.
This release applies to and covers the uses listed, but are not limited to: photographic, audio or video recordings which may be used for the following purposes:
presentations, brochures, educational courses, informational presentations, on-line educational courses, educational videos and all DCF social media platforms,
statements or
I understand that I do not have to agree to this release of information, but do so knowingly subject to the following restrictions (check the applicable
"not Applicable"); I hereby release, discharge, and covenant not to sue the State of Connecticut, Department of Children and Families from any claims
arising from the use of the Performance including, but not limited to, any claims that CT DCF has defamed me, invaded my privacy, or infringed my moral
rights, rights of publicity or copyright. I hereby waive the right to inspect or approve any uses of the Performance.
I further agree that this agreement shall be governed by the laws of the State of Connecticut without regard to its principles of conflicts of laws, and shall
be binding on me, my heirs, assigns, licensees, and legal representatives. If any term of this agreement is determined to illegal, unenforceable, or in
conflict with any law, the validity of the remaining portions will not be affected thereby.
I do
I do NOT
Agree to have my full first and last name released
I do
I do NOT
Not Applicable
Agree to have ONLY my first name released
I do
I do NOT
Agree to have my child(ren)'s full first name and last name released
I do
I do NOT
Not Applicable
Agree to have ONLY my child(ren)'s first name released
I do
I do NOT
Agree to have the town/city of my family's residence released.
I do
I do NOT
Agree to allow my face to be shown in pictures or video to be released
I do
I do NOT
Agree to allow my child(ren)'s face(s) to be shown in pictures or video to be released
I do
I do NOT
Agree to the release of information about me and my family but without any identifying information released.
I understand that authorizing the use or disclosure of this information is voluntary, and I do not need to sign this form to receive services. I understand
that the confidentiality of my information is protected by federal and state confidentiality laws. I grant to the State of Connecticut, Department of Children
and Families (“CT DCF”) the right to copy, reproduce, photograph, distribute, transmit, broadcast, exhibit, transcribe, digitize, display, copyright, license,
transfer, reproduce, translate, modify, edit or otherwise use throughout the world in all media now existing and hereinafter developed for educational,
promotional or other purposes that support CT DCF’s mission, in accordance with my above selected statements. My authorization will remain in effect in
perpetuity except that I retain the right to revoke this release at any time. I understand that these rights are granted to CT DCF and may be used in whole
or in part in any media without compensation.
I have read and understood this agreement, and I am over the age of 18. I represent and warrant that I have the legal right and power to grant CT DCF
the rights granted above. Accepted and agreed to by:
First and Last Name (Print)
Signature
Date
Name of Parent or Guardian, if child is under 18
Signature of Parent or Guardian, if child is under 18
Date
Address
City, State
Zip
Name of Photographer
Signature of Photographer
Date
STATE OF CONNECTICUT
www.ct.gov/dcf
This completed and signed form must be returned to the DCF Legal Division,
along with a copy of the information, photo, video or all three attached