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2. 
4. First & Last Name of individual(s) represented in images & recordings*
6. Select an option below regarding permission for images and recordings to be used by TCHD for educational and/or promotional purposes.*

   1. Permission is granted.

   1. Permission is not granted.
8. Contact Email *
10. Client/Parent/Guardian e-Signature *
12. Date mm/dd/yyyy*
    Date mm/dd/yyyy
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14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

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