Photo Release Form

The Kentucky Oral Health Coalition is comprised of dental professionals, parents, manage care organizations, teachers, advocates and many businesses working together to improve the oral health of all Kentucky residents.  If you are willing to allow us to use your, or your child’s image, please complete the form below and upload pictures. You must be a parent or guardian of the child in the photographs to provide permission for us to use the images.

You can upload 4 pictures to this form. If you want to send in additional pictures, there are instructions after you submit this form on how to do that. If you have any questions, please email mkalra@kyyouth.org.

By filling out this form, you commit to the following:

I, the undersigned, do hereby grant permission to Kentucky Oral Health Coalition to publically use the submitted photograph(s) of me and/or my minor child(ren). I understand that the images may be used in Kentucky Oral Health Coalitions’ print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Photo Release Form
















  • Clicking Submit will serve as an electronic signature verifying that you permit Kentucky Oral Health Coalition to publicly use photos of yourself, or your children if they are under 18.