Photo Release

  • Child Information

  • 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.
  • MM slash DD slash YYYY
  • Parent/Guardian/Caregiver Information

    I (parent/guardian/caregiver) certify that I am a custodial parent and have the aforementioned rights to assign.