I, _____________________ grant permission to South Florida Lower Extremity Center to use my image (photographs and/or video) for use in media publications including:
Facebook, Instagram, Brochures, Email Blasts (Mailchimp), or Other __________
I hereby waive any rights to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, weather that use is known to me or unknown.
Please initial the paragraph below which is applicable to your present situation:
I am 21 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
Patient Name: ________________________________
Name: (Please print): __________________________
Address: ____________________________________
Signature of parent or legal guardian: (if under 21 years old of age)
_________________________________________