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This field is for validation purposes and should be left unchanged.

I understand Catholic Social Services (CSS) wishes the right and permission to use and/or publish my or my family members’ photograph, voice and/or image in any media for promotion of Catholic Social Services’ programs, advertising or other lawful purpose.

Media will be defined to include photographic, audio, visual, electronic, or combined recordings of CSS facilities, clients and staff in any medium in which a likeness, voice, or discussion may be recorded in print, audio or visual, electronic or display. Media includes newspapers/magazines (articles and advertising), radio (audio recordings), television (live and/or video recordings); print media such as brochures, newsletters, etc.; other electronic media such as web sites on the Internet; and other visuals such as display.

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(Guardian must sign)
A copy of the signed consent form will be sent to this email address.
Address
Program*
Signature*

Revised 12/08/2025