Sample Photograph Release Form


FOR VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, I hereby grant (Name of Clinical Facility) the irrevocable right and permission, throughout the world, in connection with the photograph(s) that were taken of me or which I provided to (Name of Clinical Facility), (copies of which photographs are annexed hereto and made a part), the following: the right to use and reuse, in any manner at all, said photographs, in whole or in part, modified or altered, either by themselves or in conjunction with other photographs, in any medium or form of distribution, and for any purposes whatsoever, including, without limitation, all promotional and advertising uses, and other trade purposes, as well as using my name in connection therewith, if (Name of Clinical Facility) so desires.

I hereby forever release and discharge (Name of Clinical Facility) from any and all claims, actions and demands arising out of or in connection with the use of said photographs, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees and legal representatives of (Name of Clinical Facility).

Please check one:

_____ I am over the age of eighteen years and I have read the foregoing and fully and completely understand the contents.
_____ I represent that the subject of the photographs is a minor and that I am the parent of the minor and that I have read the foregoing and fully and completely understand the contents.

_____________________________________   __________
Subject or parent's signature                                            Date

Print or type both subject's and parent's name

Phone: _________________________________

Address: _______________________________


(Name of Clinical Facility) staff signature and title

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