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Photo and Video Release Form

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.

 

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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