TX HHS Form 5403. Media Release Authorization to Photograph and Record a Volunteer or Service Recipient

Form 5403 is an authorization form used by Texas Health and Human Services (HHS) to obtain written consent from a volunteer or service recipient to be photographed, audio recorded, or video recorded. The form documents an individual’s permission for HHS to use these materials for specific program-related purposes such as education, training, and public information.

This form is designed to protect individual rights while allowing HHS programs to responsibly document and share their activities.

Purpose of Form 5403

The primary purpose of Form 5403 is to clearly document whether an individual agrees to allow HHS to create and use photographs, audio recordings, or video recordings of them. The authorization applies only to defined, lawful uses connected to HHS programs and does not affect eligibility for services or benefits.

Importantly, signing this form is voluntary. Refusing to sign does not result in denial of services, benefits, or payment processing.

When This Form Is Required

Form 5403 is typically used in the following situations:

• When a volunteer participates in an HHS-sponsored program or event
• When a service recipient may appear in photographs or recordings for training or outreach
• Before recording interviews, educational sessions, or promotional materials
• During public-facing events organized by HHS programs

The form is not required if no photography, audio recording, or video recording will take place, or if the individual chooses not to provide authorization.

Who May Complete and Sign the Form

Form 5403 may be signed by:

• The volunteer or service recipient
• A parent of a minor service recipient
• A legal guardian or authorized representative

If someone signs on behalf of another person, their relationship to the service recipient must be clearly stated.

Explanation of Key Sections

Authorization Statement

This section explains what the individual is authorizing. By signing, the individual grants HHS permission to photograph and record them and to use those materials for program development, education, and promotion.

Permitted Uses of Materials

The form specifies that materials may be used for:

• Training and educational purposes
• Public information materials
• Local news and program promotion

This helps ensure transparency about how images and recordings may appear.

Ownership of Materials

This section clarifies that all photographs and recordings become the exclusive property of HHS. The individual relinquishes ownership rights to materials created while the authorization is in effect.

Public Event Disclaimer

HHS explains that it cannot control third parties who attend public events and independently take photographs or recordings. This distinguishes official HHS use from unrelated public activity.

Right to Refuse or Revoke Authorization

The form clearly states that individuals may refuse to sign or revoke authorization at any time by submitting a written, signed statement to the department that received the original authorization.

Signature and Contact Information

The final section captures the printed name of the service recipient, contact information, signatures, dates, and, if applicable, guardian or representative details.

Practical Tips for Completing Form 5403

• Read the permitted uses carefully before signing.
• Ask how and where materials are likely to be used.
• Ensure names and dates are clearly printed and legible.
• Keep a copy of the signed form for your records.
• Submit the form using the method requested, usually by email.

Common Mistakes to Avoid

• Assuming the form is mandatory when it is voluntary
• Signing without understanding ownership of materials
• Failing to indicate guardian or representative status
• Leaving signature or date fields blank
• Believing revocation removes past materials automatically

Legal and Regulatory Context

Form 5403 supports privacy and consent requirements applicable to state agencies. HHS uses this form to document informed consent for media use while ensuring that individuals’ rights to refuse or revoke authorization are respected. The form also clarifies limits on HHS responsibility for third-party recordings at public events.

Real-Life Situations Where This Form Is Used

• A volunteer agrees to appear in a training video for staff education.
• A service recipient participates in a program success story shared publicly.
• An HHS event includes photography for informational materials.
• A guardian authorizes limited media use for a minor service recipient.

Documents Commonly Associated with This Form

• Volunteer onboarding paperwork
• Program participation forms
• Event registration materials
• Written revocation statements, if applicable

Frequently Asked Questions

Is signing Form 5403 required to receive services?

No. Services and benefits are not affected if you refuse to sign.

Can I revoke my authorization later?

Yes. You may revoke authorization in writing at any time.

Does revocation remove existing photos or recordings?

No. Materials created while authorization was valid may remain in use.

Who owns the photographs and recordings?

HHS owns all materials created under this authorization.

Does this cover photos taken by the public?

No. HHS is not responsible for third-party recordings at public events.

Can a guardian sign for a service recipient?

Yes, if they are legally authorized and list their relationship.

Related Forms

• Volunteer Application Form
• Program Participation Agreement
• Consent to Share Information Form
• Revocation of Authorization Statement

Form Details

• Form Name: Media Release – Authorization to Photograph and Record a Volunteer or Service Recipient
• Form Number: 5403
• Agency: Texas Health and Human Services
• State: Texas
• Revision Date: June 2020