PHOTO/MEDIA RELEASE FORM

PHOTO/MEDIA RELEASE FORM
Child's Name

First NameLast Name
Guardian's Name

First NameLast Name
Date of Form Completion

MonthDayYear
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 postswebsiteblog postsbrochures for doctors offices/daycaresevent invitations/promotionspictures hung up in the officeeducational 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

Clear
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

Clear
Should be Empty:

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.