Fundamental Therapy Inc will take all steps to ensure that these images are used soley for the purposes they are intended. If you become aware that these images are being used inappropriately, or wish to revoke this permission, please inform staff immediately. I herby hold harmless and agree to release and forever discharge Fundamental Therapy Inc from any and all claims, demands, and causes of actions which I, my heirs, representatives, executors, administrators, or any other person acting on behalf of myself or on behalf of my estate by reason of authorization. I have authorized to make the above decisions and represent any family members/guardians involved.

I, Parent/Guardian First & Last Name , give Fundamental Therapy Inc. permission for my child,   Child's First & Last Name , to be photographed and or videotaped during Physical Therapy treatment sessions. Photographs and videos may be shared with the following (check those that apply):
Initials  Physical, Occupational, Speech Therapist for training, evaluations, and treatment purposes.
Initials  As a record of therapeutic progress.
Initials  As a description of therapeutic procedures, exercises, or activities for communication with parent when unable to attend therapy treatment sessions. 
Initials  I will allow pictures or videos of my child to be used in Fundamental Therapy marketing publications , website, and social media.
Initials  I will allow my written testimonial to be used in Fundamental therapy marketing publications, website and social media.

Initials  I do not want my child videotaped/recorded.