Participation With Care

Parent & Legal Guardian Permission

The Wells of Love with Kit welcomes meaningful participation while taking special care when a participant is under the age of 18. This form allows a parent or legal guardian to clearly identify what participation they authorize and how the minor's contribution may be used.

This form is for participation—not simply listening. A parent or legal guardian does not need to complete this form merely for a minor to listen to The Wells of Love. This form is intended for activities such as listener submissions, call-ins, recorded contributions, interviews, appearances, photographs, audio, video, or other participation involving the program.

Parent or Legal Guardian

Full Name *

Email Address * A confirmation copy of this authorization will be sent to this email address.

Phone Number

Relationship to Minor *

Minor Participant

Minor's Full Name *

Minor's Age *

What Are You Authorizing?

Select all that apply. *

Submit a Love Note at The Wells Participate in Give Them Their Flowers Participate in a live call-in Provide recorded audio or a voice contribution Participate in an interview or guest appearance Participate through photographs or video Other participation

If Other, Please Describe

Where May the Authorized Content Be Shared?

Select each place you authorize. *

The Wells of Love radio show, including authorized broadcasts, encores and rebroadcasts The Wells of Love website The Wells of Love social media Promotional materials for The Wells of Love within the permissions authorized on this form Private Only — do not intentionally broadcast, publish or publicly share the participation Permission for one platform does not automatically authorize another platform.

How May the Minor Be Identified?

Choose one. *

Full name First name only Initials only Anonymous

Limitations or Special Instructions

Is there anything you do not authorize or anything The Wells should know? Example: “Radio only; please do not use photographs or social media.”

Parent / Legal Guardian Authorization

I certify that I am the parent or legal guardian of the minor identified above, or that I otherwise have legal authority to provide this consent. I authorize the participation and uses I have specifically selected on this form. I understand that permission for one use or platform does not automatically authorize another use or platform. I have read and agree to the Listener Participation & Submission Terms and acknowledge the Privacy Policy.

The date and time of this authorization will be recorded automatically when the form is submitted.

The information submitted through this form is used to document and administer permission for a minor's participation in The Wells of Love with Kit. Submission of permission does not guarantee participation or selection.

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