Media Release Form
I give permission to Sarah Fraske from Sebby’s Studio to photograph/ record (please circle) my artwork created during art therapy sessions for the following purposes [please check the appropriate box(es)]:
□ Educational purposes (training, supervision, research, publication)
□ Promotional materials (website, social media, brochures)
I understand that comments and case material may be used for scientific and educational purposes only. I understand that all photographs and observations will be presented in a respectful and professional manner. I understand that this means that the participant’s personal information will not be used unless permission is given through a separate signature at the bottom of the page. All names and personal information on artwork will be covered before photographed or published. Confidentiality of the participant’s name will be maintained unless otherwise agreed and signed upon at the bottom of the page.
Client’s Name: _____________________________ Age: _____ DOB: __________
Parent/Guardian Name (if applicable): ____________________________________
Client’s Signature: ____________________________________________________
Signature of Parent/Guardian (if applicable): _______________________________
I give permission to Sarah Fraske from Sebby’s Studio to share first my name with my artwork to be viewed.
Client’s Name: _____________________________ Age: _____ DOB: __________
Parent/Guardian Name (if applicable): ____________________________________
Client’s Signature: ____________________________________________________
Signature of Parent/Guardian (if applicable): _______________________________
Sebby's Studio for Art Therapy 