By submitting this form through this web portal, you acknowledge and accept the potential risks associated with transmitting your personal information via unencrypted email and electronic messaging. You understand these risks and wish to proceed despite them. By clicking "Yes, I want to submit this form," you agree to hold Brighter Vision harmless for any unauthorized use, disclosure, or access of your protected health information transmitted through this electronic means.

Additionally, you hereby grant permission to Special Needs Services of Ray County and its assignees to photograph or record video of you or your child during participation in public SNS events. You waive any rights to compensation related to the use of your or your child's name, likeness, or voice. The purpose of this release is to support publicity efforts for SNS programs.