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

The TX HHS Form 5403, Media Release Authorization to Photograph and Record a Volunteer or Service Recipient, is a crucial document for individuals who wish to participate in public events or activities while allowing Texas Health and Human Services (HHS) to capture their image or likeness.

This form grants permission to HHS to photograph, audio and video record the individual for program development, education, and promotion purposes. The authorization also permits the use of these materials in various formats, including training, public information, local news, and promotion. Notably, the individual retains the right to refuse or revoke this authorization at any time.

Key features of this form include the required contact information and signature of the service recipient, as well as the option for a guardian or representative to provide their own contact information and signature. Additionally, the form highlights the responsibility of HHS to respect the individual's right to revoke their authorization and make every effort to no longer use their photographs or recordings in materials created after revocation.

• This form is typically used by individuals who wish to participate in public events or activities while allowing Texas Health and Human Services (HHS) to capture their image or likeness.
• The authorization grants permission for HHS to photograph, audio and video record the individual for program development, education, and promotion purposes.
• The form allows individuals to refuse or revoke their authorization at any time.