Photo Consent Form printable pdf download

Photo Consent Form

PHOTO CONSENT FORM

I, ______________________________________________ grant permission to

Jumpstart Therapy , LLC to use photograph(s), video or electronic media images of

myself or child as it relates to occupational therapy. I give permission to have such

photographs, video or electronic images

___displayed in-office

___sent to me via mail, email or text

___used for educational purposes in-office

___used for educational purposes out of the office

__used for promotional or advertisement purposes as it relates to Jumpstart Therapy,

LLC (such as brochures and website)

I understand that I may revoke this authorization at any time by notifying Jumpstart

Therapy, LLC/Kimberly Geary in writing. The revocation will not affect any actions taken

before the receipt of this written notification. Images will be kept as long as they are

relevant and after that time destroyed.

Parent/Guardian Name___________________________________________________

Child’s Name____________________________________________________________

Phone __________________________ Email__________________________________

Signature ________________________________ Date __________________________

***If used for Promotional or Advertisement Purposes ***

Image(s) Description

________________________________________________________________________

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Photo Consent Form