Peak Potential Therapy Homepage
HOLLY REIMANN, MA CCC-SLP
Peak Potential Therapy

Therapy Treatments & Resources for Families with Children
Affected by Autism & Related Disabilities in Cleveland / Akron Ohio.

10 Great Reasons to Choose Peak Potential Therapy
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SMILE Summer Camp is a Therapeutic Day Camp - Click to find out more!

PHOTOGRAPH RELEASE
for children under 18 years of age



Photograph / Video Release

I (parent/guardian/caregiver) hereby grant to Peak Potential Therapy LLC, the right to interview, photograph, and/or video record my dependent and use the photo and/or other digital reproduction of him/her in any and all of its publications and in any and all other media, whether now known or hereafter existing. I understand and agree that these materials will become the property of Peak Potential Therapy LC and will not be returned. Additionally, I waive any right to any compensation arising or related to the use of the photograph.

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I (parent/guardian/caregiver) certify that I am a custodial parent and have the aforementioned rights to assign
                     First Name*
                     Last Name*
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                     Phone Evening
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We respect your privacy. Under no circumstances will we use your personal information for any purpose other intended.
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