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Video Tape Permission

In order to video tape my son, CK, I must have permission from all parents of children that may come in contact with CK during video taping. Video taping occurs to teach parents of CK and train Aides how to better teach CK to interact with his peers.



Please sign the form below. If you have any questions about video taping, CK, or autism, please call, email, or visit our website:



John Doe

Home 555-1212

Work 555-2121

CK's team appreciates your interest and cooperation in helping,

John Doe

Consent for Photographs, Movies, or Television

I, the undersigned, hereby authorize photographs and/or movies of ____________________________________(name of participant) by the representatives of the above-named program or other designated persons to be viewed by the above-named program staff in contributing to the educational development of this staff in the advancement of teaching techniques and program activities.

_________________(date)

_______________________________(signature of participant - if applicable)

_______________________________(signature of parent/guardian)

I further agree that the above-named program may use or permit other persons to use the nagatives or the prints prepared therefrom for any such educational or advertising purposes in such manner as may be deemed benefitial and necessary for clinic and/or United Way. It is understood that the individual's name will not be visible during such usage unless permitted by the undersigned.

_________________(date)

_______________________________(signature of participant - if applicable)

_______________________________(signature of parent/guardian)






I allow my child, _______________________________, to be video taped at [Place] by John Doe. I understand that the video tape will be used in the strictest of confidence and only viewed by the aforementioned people and future new therapists for CK. I understand that the even though the main point of video taping is to observe and critique CK, my child may also be videotaped in the process.





Parent/legal guardian's Signature ____________________________________________



Date ___________________________________________________________________

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