PHOTO/MEDIA RELEASE FORM
Child's Name
First Name
Last Name
Guardian's Name
First Name
Last Name
Date of Form Completion
-
Month
-
Day
Year
Date
Please read the form below and sign next to consent or do not give consent based on your personal preferences regarding photos and videos taken at Communication Cottage Therapy.
Please check off the boxes that would indicate the means that photos/videos can be utilized for Communication Cottage Therapy:
social media posts
website
blog posts
brochures for doctors offices/daycares
event invitations/promotions
pictures hung up in the office
educational content
Please sign under ONE of the options below. Thank you kindly
I give consent for photos and videos to be utilized for marketing/educational purposes via the means that I have checked off above.I understand that my child's name will not be utilized with any of these means
Signature
I do not consent for photos/videos to be taken of my child for these above purposes. If I reconsider I understand that I would need to complete a new form to have on file.
Signature
Submit
Should be Empty: