Name of Parent/Guardian Responsible for Group Attendee *

First Name

Last Name

I authorize NeuroVibes Music Therapy LLC (“NeuroVibes”) to release information regarding my child. This information is in the form of photo or video (“Information”). (please check ALL that apply. You are free to check any number from zero to all of the spaces):

This Information can be shown to therapists at state, regional, national, and international conferences as part of NeuroVibes presentations.

This Information can be shown at other professional conferences and in-services (e.g. neuroscience, psychology, medical, etc.) as part of NeuroVibes presentations.

This Information and be shown to college students and professionals for the purpose of education and training

This Information can be shown to non-therapists as part of public presentations or advertising

This Information can be used in publications (including but not limited to newspapers, radio broadcasts, books, brochures, magazine articles, and Internet).

This Information can be used for data collection and verification by treating professional and colleagues