Media Release | EBS Children's Therapy of Georgia

I grant permission for my child to be photographed or videotaped by Chandler Speech and Language Services LLC.*
- Yes
- No
I grant permission for my child to be photographed or videotaped for:*
- therapist use ONLY (i.e. review, further information for evaluation + therapy, etc.)
- display in the Chandler Speech office (i.e. on recognition board, pictures on walls)
- educational purposes (i.e. teaching/sharing info between therapists)
- Marketing and/or promotional use (i.e. website, brochures, etc.)
Child's Name*
First Last
Parent's Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
Signature*