This agreement must be signed by the Instructor or clinician who will be using audio/video
materials and returned to THE TRAINING TAPES by fax or delivered mail before any videotape
is shipped.
The person(s) signing this Agreement guarentees that: To protect the confidentiality of families
who appear on the videotape and in accordance with the conditions of the consent they have granted for the use of audio/video
recordings:
a. This material will be shown only to mental health professionals or students in professional graduate or clinical
training programs.
b. This material will not be duplicated.
Signature _____________________________________
Title _________________________________________
Institution _____________________________________
Mail payments of $ 95 (Individual) or $ 200 (Institutional) per video. Make checks payable to THE
TRAINING TAPES. This Agreement can be printed out on any ordinary computer printer and faxed
directly to 212.777.0207, or sent along with payment to THE TRAINING TAPES.
Name of videotape or DVD(s) Specify DVD or Tape format
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Name _______________________________________
Institution_____________________________________
Address______________________________________
City__________________________________________
State ____________________ Zip ________________
Phone ___________________ Fax________________
email ________________________________________
