Child's Name
Date
/
Month
/
Day
Year
I give my permission for my child's picture/video to be used by Wee Speech, P.C. for the purpose of training other professionals.
I give my permission for my child's picture/video to be used by Wee Speech, P.C. for marketing/publicity.
I do not wish my child's picture/video to be used for any purpose other than training his/her specific therapy team.
I understand that I will be informed of the use of my child's picture/video prior to any occurrence.
I agree to have pictures/videos of my child's therapy sessions stored in a password protected file on Google drive. I am aware that this file will only be shared with myself and team members involved in my child's care with my permission.
I understand that this permission can be revoked at any time.
ParentGuardian Printed Name
Signature
Date
/
Month
/
Day
Year
Wee Speech, P.C.
8707 Skokie Blvd. Ste 402
Skokie, IL 60077
(847) 329-8226
www.weespeech.com
Save
Submit
Should be Empty: