By signing below, I consent to the use of my name, voice, likeness, photograph, and/or video by Empower Rehab and Wellness Inc., its officers, employees, agents, affiliates, volunteers, and successors, for the purpose of promoting the goals and objectives of said companies. I fully understand that my image may be represented in informal, advertising and/or media release materials and could potentially reveal to the public my name, voice, and/or likeness. I hereby waive any right of privacy, anonymity, and/or confidentiality conferred by state, federal, or other recognized laws.
I hereby release and forever discharge said companies, its officers, employees, agents, affiliates, volunteers, and successors for any liability from any injury or damage to or loss of privacy, anonymity and/or confidentiality arising out of or in connection with the reproduction, exhibition, or broadcast of my name, voice, likeness and/or my statements in any format either directly or with the aid of a machine or device, including by affidavit, photograph, film, videotape, or sound recording.
Please sign below only if you have read the above Photo and Video Release and understand and agree to the terms outlined in this form.