Name *

First Name

Last Name

Phone

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Informed Consent *

I, (first and last name), HEREBY GRANT PERMISSION for KAF COUNSELING AND CONSULTING, INC. (“KAF COUNSELING”) to record my presentation by videotape, audiotape, podcast recording, digital means or otherwise. I affirm that the presentation is my original work, that I am the legal owner of the presentation and therefore I have authority to sign this Consent Form. This recording is being made by KAF COUNSELING. for educational purposes and clinical research to promote broader understanding of the presentation content and subject matter. I (initial), HEREBY GRANT PERMISSION to KAF COUNSELING AND CONSULTING, INC. to: [1] rebroadcast and/or show this presentation in conjunction with KAF COUNSELING services, forums, presentations, and/or communications; [2] use all or part of this presentation in the creation of derivative works that could be posted on YouTube, Facebook, iTunes, or other open web sites; [3] incorporate all or any portion of the recording in derivative works or compilations in any form or media in connection with KAF Counseling publications and/or public relations media; [4] duplicate the recording for the purpose of preserving it, or replacing a damaged version; and [5] duplicate the recording for educational purposes. I understand that I am not entitled to receive any compensation for the recording or KAF COUNSELING AND CONSULTING, INC’s use thereof, as described above, and that the recording may be archived for future use. I, (first and last name), HEREBY release KAF COUNSELING AND CONSULTING, INC. and its successors and assignees from any liability and hold them harmless by virtue of my videotape, audiotape or podcast recording. THE PARENTING PEAK PERFORMERS PODCAST INFORMED CONSENT FORM KATHY A. FEINSTEIN, MS of KAF COUNSELING AND CONSULTING INC, will be utilizing this podcast audio recording technology in THE PARENTING PEAK PERFORMERS PODCAST. The recordings from this Podcast segment may be used for assessment, educational, clinical, or research purposes (e.g. Content may be posted online for use in web-based or hybrid forums, used to assess the instructor or participant’s skills, or shared in professional venues). KAF COUNSELING AND CONSULTING INC. may use the recordings for other professional purposes including but not limited to: program assessment, fundraising, advertising, KAF COUNSELING AND CONSULTING INC. websites, podcasting, research or any other purpose on behalf of KAF COUNSELING AND CONSULTING INC. services. By signing below, I understand that KAF COUNSELING AND CONSULTING INC. may: [1] rebroadcast and/or show this podcast segment in conjunction with KAF COUNSELING AND CONSULTING INC.’s services, [2] use all or part of this segment in the creation of derivative works that could be posted on YouTube, Facebook, iTunes, or other open websites; [3] incorporate all or any portion of the recording in derivative works or compilations in any form or media in connection with KAF COUNSELING AND CONSULTING INC. publications and/or public relations media; and [4] duplicate the recording for the purpose of preserving it, replacing a damaged version or duplicate for educational purposes. I understand that the recordings belong to KAF COUNSELING AND CONSULTING INC., and I will not receive payment or any other compensation in connection with the recordings. I HEREBY release KAF COUNSELING AND CONSULTING INC. and KATHY A. FEINSTEIN, MS and its successors and assignees from any liability and hold them harmless by virtue of my video and/or audio-recording. I UNDERSTAND THE PURPOSE AND INTENT OF THE PODCAST AUDIO RECORDING SYSTEM. I GIVE MY CONSENT FOR MY IMAGE/RECORDING TO BE USED AS DESCRIBED ABOVE.

Yes I provide consent

Today's Date *

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