Photo Release Form

"*" indicates required fields

At Chatterbox Pediatric Therapy, we love to celebrate the milestones reached by the children we treat as well as all the fun we have at work! Please note that we will not post any photos or videos of your child unless written permission is given by signing the form below.

ACKNOWLEDGEMENT*

I, the parent or legal guardian DO grant Chatterbox Pediatric Therapy my permission to use the photographs taken during therapy for any legal use, including but not limited to publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

I, the parent of legal guardian DO NOT grant Chatterbox Pediatric Therapy my permission to use any photographs of my child taken during therapy for any public purposes, including but not limited to publicity, advertising and web content.

Child Name*

Parent/Guardian Name*

Parent Guardian Signature*

Date*

Photo Release Form

Photo Release Form

Our Locations

Pooler

Richmond Hill

Photo Release Form

Have Questions? Contact Us

Our Locations

Pooler

Richmond Hill

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