Name of Minor
*
First Name
Last Name
Age
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Name of Parent/Guardian
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization, Release, and Consent
I DO NOT authorize Caterpillar Playground Occupational and Physical Therapy to take any photos or videos for purposes other than security.
I authorize Caterpillar Playground Occupational and Physical Therapy to take:
Photos of my child during therapeutic activities
Videos of my child during therapeutic activities
Photos of my child, but not during therapeutic activities
Videos of my child, but not during therapeutic activities
I authorize the use of my child's photos/videos (as marked above) for purposes of:
Documenting progress in therapy
Research and data collection
Education of students of occupational therapy
Educational presentations
Marketing and advertising, which may include print materials, company website, and social media (i.e., Facebook, Twitter, Instagram, TikTok, etc.) and may include altering, editing, copying, and distribution.
When using my child's photo or video:
I give permission for Caterpillar Playground Occupational and Physical Therapy to show my child's face.
I would like my child's face to be blurred or covered.
I give permission for Caterpillar Playground Occupational and Physical Therapy to use my child's FIRST name.
I do not give permission for Caterpillar Playground Occupational and Physical Therapy to use my child's name.
I agree that the media items belong to Caterpillar Playground Occupational and Physical Therapy.
I understand that neither I, nor my child, will receive any monetary compensation.
I understand that by allowing taking and/or sharing of my child's photos and videos, some information about my child is no longer confidential as it relates to medical care and HIPAA laws.
I understand that I can revoke this permission by giving written notice at any time, but that in the event the information has already been shared, the revocation does not apply to those items.
Signature
*
Date Signed
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: