PHOTO/VIDEO CONSENT FORM

I grant permission to Caitlin A. LaRussa/Grow Together OT Services to use photograph(s) or video of my child as it relates to occupational therapy.

I understand that I may revoke this authorization at any time by notifying Caitlin A. LaRussa in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be kept as long as they are relevant and after that time destroyed.