Consent of Audio / Video Recording

Fairmount Speech and Swallowing Therapy

Philadelphia, PA

contact@fairmountspeech.com (215) 645-2699
Consent of Audio / Video Recording
(client or parent/guardian name) give consent to

I_______________(client /guardian name) give consent to Fairmount Speech and Swallowing Therapy or any party authorized by Fairmount Speech and Swallowing Therapy to photograph and/or video record _________________ (client name) in connection with his/her therapy sessions, for any purpose subject to the therapist’s discretion including evaluation purposes and demonstration of progression of his/her skills. I reserve the right to revoke this agreement at any time. I understand that my right to revoke must be done via email or writing.
I am the client, parent or legal guardian of the person named below and have the legal authority to execute this consent and release.
Print Name of Client
Date

Month Day Year
Date
Signature of Client or Legal Representative

Clear
Relationship to Client
Release of Photographs / Videos
Should be Empty: