By selecting the “Yes, I authorize” checkbox below and submitting this form, I, the parent/guardian of the child listed below, gives consent to Sound Beginnings Speech Therapy Services or any party authorized by Sound Beginnings to photograph and/or video record the child listed below 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 skills.

Parent/Legal Guardian's Name

First Name

Last Name

Checkbox

I authorize Sound Beginnings to use pictures of the child listed on this form for promotional purposes (e.g. brochures, website, etc.) I acknowledge that I will receive no financial compensation for providing consent since my participation with Sound Beginnings in providing my consent and release is voluntary. I hereby release Sound Beginnings, their contractors, and/or any third parties involved in the creation or publication of content for Sound Beginnings from any and all liability that may arise in connection with the expressed and implied use of all photographs and videos outlined in this form. I reserve the right to revoke this agreement at any time. I understand that my right to revoke must be completed in writing.

Yes, I do authorize

No, I do not authorize

Child's Name

First Name

Last Name

Today's Date

YYYY

Parent/Legal Guardian's Relationship to Child