Media Release Consent Form

Consent and Release of Photographs / Videos
Client Name

First NameLast Name
Parent/Guardian Full Name

First NameLast Name
Relationship to Client
Please check all that apply

I, the parent/guardian, give consent to Northwest Pediatric Therapy and its member organizations (including, but not limited to, Northwest Pediatric Speech Therapy, and Sprout Pediatric Therapy) or any party authorized by Northwest Pediatric Therapy to photograph, video, and/or audio record the client in connection with his/her therapy sessions, for any purpose subject to the therapist’s discretion including but not limited to educational publication, for teaching purposes, and demonstration of progression of his/her skills.
I am the client, parent or legal guardian of the person named below and have the legal authority to execute this consent and release.
Signature of Client or Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Consent and Release of Photographs / Videos