Pediatric Consent for Photographing and/or Videotaping

As business owners, as well as local and national presenters we often find it useful to take and share photographs and/or video clips of evaluation and/or treatment sessions of the individuals we support. Photographs and video clips may be used in public trainings as well as personal marketing activities (e.g., website, brochure). We would appreciate your consent to photograph and/or videotape.
Initial here I hereby authorize Britteny Asher and/or Ashley Northam to videotape evaluation and/or treatment sessions. Britteny Asher and/or Ashley Northam are authorized to show these videotapes in public and educational settings for the purposes of instruction and training. I give my permission for Britteny Asher and/or Ashley Northam to disclose relevant clinical information when showing videotape segments or photographs.
Initial here I hereby authorize Britteny Asher Consulting to use video clips and or photographs for marketing purposes (website, brochure). I understand no identifying information will be shared about my child in this use.
Initial here I understand the records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time.
Name of Individual to be photographed/videotaped *

Name *
Title/Relationship *
Date *
By clicking submit, I am authorizing Britteny Asher Consulting to photograph/videotape for the purpose(s) I have initialed above.