Release for Photographs, Audio, and Video Imagery

I give authorization to StarBright Applied Behavior Analyst to obtain and utilize images or audio of Client as identified below. I understand these images may be taken by an agency owned camera, a disposable camera, or a staff or contract professional’s personal device. Further, I understand that some electronic devices may include a direct connection to the internet. As such, images may be subject to accidental or intentional forwarding to the public domain. This release will expire one year from the date of my signature or upon written notice to StarBright Applied Behavior Analysts.*

AgreeDisagree (Skip to signature and date line below)

Advanced Permissions

	Yes	No
Photo - Staff Training
Photo - Intra-agency photo albums & presentations
Photo - Sharing with Parent/Guardian/Legal Representative
Video - Staff Training
Video - Intra-agency photo albums & presentations
Video - Sharing with Parent/Guardian/Legal Representative
Audio - Staff Training
Audio - Intra-agency photo albums & presentations
Audio - Sharing with Parent/Guardian/Legal Representative

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain support and services from StarBright ABA.

I understand that I may withdraw my authorization at any time by providing written notice to StarBright ABA. I understand also that such withdrawal of my authorization may not be effective to prevent disclosure of information previously authorized or to stop previous action that has been taken in reliance on this authorization.

My signature means that I have read this form and/or have had it read to me and explained in language I can understand. I know what information will be disclosed and give my voluntary consent to its release.

My signature means that, if I am not signing for myself, I have the legal authorization to sign for the identified individual.

My signature confirms that I am the legal representative/guardian for the identified individual

Client Name*

First NameLast Name

Client Date of Birth*

Date

Parent/Guardian/Legal Representative Name

First NameLast Name

Parent/Guardian/Legal Representative Signature*