Media authorization

We sometimes use images, names, and information about participants or others as we tell our story in the community. Complete the form below to give The Learning Well and La Clinica permission to use your image, name, and information publicly.

  • If you are a program participant, doing this won’t affect the services you get from us. Signing means that any health or other information you share as part of an interview, photo, or recording is no longer covered by federal privacy laws and may be shared publicly by La Clinica and The Learning Well.
  • You may take back this authorization at any time in writing. Information released between the date on this form and the date you take back authorization may still be in public use.
  • If you have questions, please ask one of our employees for answers before signing the form or email us at

Thank you.

Release Form