• PHOTO/VIDEO AUTHORIZATION & RELEASE FORM:

    630-478-0480 | posna@posna.org | 1 Tower Lane Suite 2410 | Oakbrook Terrace, IL 60181

  • I,      , as either the participant or the parent or legal guardian of the participant, agree to the following:

    • I understand and agree that this is a legally binding agreement and that I have the right, power and authority to enter into it on behalf of myself and the participant.
    • I grant permission to the Pediatric Orthopaedic Society of North America (POSNA) and its members and employees the irrevocable and unrestricted right to produce the photographs and/or video recordings taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.
    • I agree that POSNA will be the sole owner of such media and can use them in any way it sees fit, without needing any further permission from me or the participant.
    • I agree that POSNA may use my or the participant’s name, likeness, voice and biographical information in connection with POSNA’s uses of the recordings or any materials submitted by me or the participant described above, without needing any further permission from me or the particpant.
    • I, on behalf of myself and the participant, hereby agree to release POSNA or any of its
    • partners, personnel or related companies for any claims and liability of any kind whatsoever, whether known or unknown, related to the use of the above mentioned materials.
    • I agree that the rights, permissions, and other terms and conditions of this agreement will be perpetual and may not be taken back or revoked by me or the participant.

    I acknowledge that I am of lawful age (18 or above) and of sound mind, and have read, understand, and consent to this Authorization and Release Form by completing the following information

  • Name of participant:         

    Name of parent/legal guardian:         

    Date: Pick a Date   

    Signature:    

  • Should be Empty: