CHILD’S NAME

Authorization to Photograph/Video Record

By signing below, I authorize clinicians at Fundamental Therapy Solutions to *

Photograph and/or video record my child for promotional purposes.

Use these photos/videos on the website for promotional purposes.

Therapists may text these photographs and/or videos via a secured medium to this phone number:

Therapists may email these photographs and/or videos via a secured medium to the following email address:

I understand that this authorization may be used on social media, website, promotional materials and/or posted in

our clinic.

I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand that authorization will expire, by law, 180 days from the date of this authorization unless I otherwise specify.

I understand that I may revoke this authorization by contacting Fundamental Therapy Solutions. The revocation

must be in writing.

Parent/Guardian (print) *

Relationship to Patient *

Parent/Guardian Signature *

Clear

Date *