College of Arts and Sciences Forms Server

By submitting this form, I hereby grant permission to the University of Kentucky and its affiliates and subsidiaries, including but not
limited to the UK Alumni Association, UK Athletics Association and UK Research Foundation, to interview, photograph and/or videotape me, or my minor child, and/or to supervise any others who may do the interview, photography and/or videotaping and/or to use and/or permit others to use information from the aforementioned interview and/or the aforementioned images in educational and promotional activities for the following without compensation:

✓ University Educational Publications/Videos

✓ University Electronics Publishing (e.g. World Wide Web)

✓ University Promotion/Advertising

✓ Local/regional/national news media (w/permission of the University of Kentucky)

If you are under the age of 18, please inform the person(s) taking photos or videos. You will be provided with a paper form that requires the signature of your parent or guardian.

I am 18 years or older

Event, location, or class the photo/video shoot is taking place (if known)

First Name

Last Name

E-mail Address

Please use your UK email address if you have one

Phone #

Address

Check this box to certify

Read more about Photo/Video Consent

Harris Center Telehealth

Name of Person Receiving Service

First Name

Last Name

Date of Service

Check if the contact person is different from the person receiving service (listed above)

Contact First Name

Contact Last Name

Email Address

Phone # (optional)

Type of Service

Individual Therapy

Group

Psychological Testing

Other

(select all that apply)

Other

Amount to be paid (USD) $

Clicking "Continue to Online Payment Form" will take you to the external merchant who is handling online payment transactions on behalf of the Harris Center. Please note that this transaction is not complete until the payment is processed. Email us at HarrisCenter@uky.edu if you have any questions or issues with completing this form.

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