Photo, Audio, Video, and Social Media Release Form
Surrey Early Speech and Language Program - SESLP
This information is entirely confidential.
Full Name of Parent/Guardian completing this form
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First Name
Last Name
Full name of child receiving services from the Surrey Early Speech and Language Program:
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First Name
Last Name
Do you give us permission to record and use any photos, video, audio, or social media posts of you and your family?
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Yes
No
I/We hereby voluntarily and without compensation authorize the use of the following media by the Society for Families of Deaf and Hard of Hearing Children of me/us and my/our child, along with any siblings that may attend the sessions.
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Photographs
Audio/Video recordings
Social media
I/We consent for these photographs, audio recordings and/or video recordings to be used by the Society for Families of Deaf and Hard of Hearing Children in the following:
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General publicity
Social media posts/campaigns
Information brochures and pamphlets
Education and training materials for professionals
Education and training materials for parents/families
Would you like to be contacted each time a photograph, audio, or video recording of you, your child, or your family is used?
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Yes
No
By signing below, I provide permission for the Society for Families of Deaf and Hard of Hearing Children to use the forms of media indicated above for the purposes indicated above:
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By signing below, I confirm that I choose NOT to give permission for the Society for Families of Deaf and Hard of Hearing Children to use photographs, audio and/or video recordings, or social media of me/us and my/our child, along with any siblings that may attend the sessions.
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Today's Date
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Submit
Should be Empty: