Video Release Agreement
For Confidential Review of Coach in a Client Session Recording
Today's Date (Click on Calendar to Choose Date)
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
First Name
Last Name
Home Street Address
City
State/Province
Zip / Postal Code
Country
First and last name of my coach whom I am authorizing to record:
First Name
Last Name
Signature (use your Mouse or Finger to create signature)
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*Note* Please forward the PDF of this completed form that you receive via email after your hit submit to your coach so they can use it for their credentialing submission.
Submit
Should be Empty: