I am a ParentLegal GuardianIndividual Full Name Sex FemaleMale Date of Birth Age Legal Guardian's/Parent Name Email Mobile Number Address City State Zip Who has custody of the child? Health Insurance Child Diagnosis Services Agency that provides service HHABehaviorTherapyWaiverOther Services Photo release NoYes I grant to Special Mothers In Action, its representatives and employees the right to take photographs and videos of me, my child and my property in connection with above-identified subject. I authorize Special Mothers In Action, it’s assigns and transferees to copyright, use and publish the same in print and/or electronically. Would you like to join our Membership Program? YesNo I agree that Special Mothers In Action may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and Web content. Please prove you are human by selecting the heart.
