Media Release
Child's Name
*
Child's Date of Birth
*
/
Month
/
Day
Year
Date
I do/do not give permission for my child to be photographed and /or videoed while attending therapy at CME, and for their photo/image, first name, and summary of their progress during therapy to be shared on social media and/or the CME website.
*
I DO give permission
I DO NOT give permission
Parent/Guardian Signature
*
Printed Name
*
Phone
*
Format: (000) 000-0000.
Email
example@example.com
Therapist(s) Name
Location Services
*
Please Select
Jonesboro Clinic
Paragould Clinic
Daycare
Other
Name of Daycare, or other location:
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