Consent to Audio/Video Tape Students

Consent to Audio/Video Tape Students
I, (Student Sign and Date Below) give my consent for Clinical Pastoral Education International (CPEI) sessions to be audio/videotaped for supervisory and educational purposes. I understand the recorded session may be reviewed in individual and/or small peer group supervision sessions, or for credentialing purposes. The guidelines of the audio/videotaping and confidentiality have been explained to me. The audio/videotapes will be erased upon the completion of the credentialing process for those supervising my Clinical Pastoral Education experience.
Date

MonthDayYear
Date
CPEI Affiliate Organization ID#
Student Name

First NameLast Name
Student E-mail*
example@example.com
CPEI Student ID #*
Name of Supervisor/Educator*
Supervisor E-mail*
example@example.com
Supervisor Signature*

Clear
Date*

MonthDayYear
Student Signature

Clear
Date

MonthDayYear
Note to Supervisors: A copy of the completed form will need to be retained for your records and should be added to the corresponding student's file.
Should be Empty: