NC DMA: MFP Video Release Form - NC Department of Health and - ncdhhs 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the MFP Participant's Name and the last four digits of their Social Security Number in the designated fields.
3. Review the statement regarding permission for video footage and picture images. Ensure you understand what you are consenting to before proceeding.
4. In the section about name usage, initial either 'may' or 'may not' based on your preference for how your name will be associated with the video content.
5. Check all applicable purposes for which the video footage and/or images may be used, such as conference presentations or outreach marketing.
6. If you do not wish to be videotaped or have pictures taken, check the appropriate box provided.
7. Fill in your printed name, date, and select whether you are signing as yourself or a guardian. Then provide your signature.
8. Complete your contact information including street address, city, state, zip code, phone number, and email address.
9. If applicable, have a witness sign in the designated area and provide their contact information as well.

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