Audio Vid auth

PERMISSION FOR AUDIO/VIDEO TAPING
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I allow TLC Georgia, to audiotape and/or videotape my child to be used for diagnostic and/or therapeutic purposes only. I understand all information will be kept confidential.

YESNO
Permission To Use Authorized Photos and Videos: I authorize Therapy and Learning Center of Georgia to publish photos and videos of my child for mass print mailings, mass email communication, social media, and Therapy and Learning Center of Georgia website. These photos and videos will be approved by ownership. I understand that I have the option to ask Therapy and Learning Center of Georgia to remove any published photos and videos of my child at anytime.

YESNO
Signature of Patient or Legal Guardian

Clear
Relationship to Patient
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TLC recognizes that parents may request that photos of your child will be taken down from website, social media, marketing, email and any other type of communication at any time by way of written request to susan@tlcgeorgia.com.
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PERMISSION FOR AUDIO/VIDEO TAPING