Release/Consent for Filming Permission 2021

Release/Consent for Filming Permission
6 Edwin Street, Morgantown, WV 26501

Phone: 304-292-0173 I Fax: 304-292-0174

PlayWorkscdc.com
I hereby grant permission to PlayWorks Child Development Center to use film or photo images of my child for display on media developed for the sole purpose of promoting PlayWorks services of Speech, Physical and Occupational Therapies to Health Care providers and the general public requiring these services.
Childs Name
Age
Relationship to child
E-Mail Address
example@example.com
Phone: (Home)
Format: (000) 000-0000.
Phone: (Cell)
Signed
Date

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