Photo and Video Permission

Photo and Video Permission

Please complete this form to provide consent for your child to be photographed or videotaped for educational purposes. Your information will remain confidential and is protected under HIPAA.
Parent/Guardian Name*
Child's Name*
I, First Name Last Name , give permission for my child, First Name Last Name, to be photographed/videotaped for the purpose of website education. This information will not be shared with any other entity.
Signature*
Date*

MonthDayYear
Date
Should be Empty: