Fillable CONSENT TO HAVE PHOTOGRAPH TAKEN (Westside Regional Center)

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CONSENT TO HAVE PHOTOGRAPH TAKEN (Westside Regional Center)

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Committed To Providing Support And Services To People With Developmental Disabilities
5901 Green Valley Circle, Suite 320, Culver City, CA 90230-6953
(310)258-4000 FAX: (310)649-1024 www.westsiderc.org
CONSENT TO HAVE PHOTOGRAPH TAKEN
Date:____________________
Re:____________________
DOB:____________________
I authorize ___________________ Westside Regional Center staff to take my/ son/daughter’s,
______________________ photograph and keep it in my/his/her file at Westside Regional Center.
This photograph shall not be reproduced or shown to anyone other than Regional Center staff without
my express permission. I do agree to allow the photograph to be shown to and used by police or other
peace officer to assist in locating my son/daughter/conservatee should I/he/she become missing. The
photograph is confidential consumer information and shall not be shown except in accordance with the
provisions of Welfare and Institutions Code Section 4514.
Date:________________________ _________________________________
Consumer
Or _________________________________
Parent of a Minor,
Guardian, Conservator
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CONSENT TO HAVE PHOTOGRAPH TAKEN (Westside Regional Center)

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Completed 7 February 2021

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