Media Release Form

IDEA Bingo Contestant

If you have been asked by an Academy member to participate in the IDEA Bingo Challenge, please include the name of the Academy member that requested you to be the photo subject. If you are not participating in the IDEA Bingo game, please disregard this section.

Bingo Contestant's Full Name (Academy Member who asked to have your photo taken)

First Name Last Name

Contestant's Email Address

example@example.com

Photo Subjects

The individual that completes this form must be the photo subject. Please note that if you are taking a photo of another individual, your photo subject must be the one to complete this form.

I, First Name Last Name , grant permission to the Academy of Pelvic Health Physical Therapy (herein referred to as "APTA Pelvic Health" or "Academy") to use and print photographs and any other form of media (i.e. video, audio) material for educational, informational and promotional purposes. The media may be used, but not limited to, in Academy print and online publications, newsletters, online articles, advertising material, website and educational materials.

I prefer that...

My complete name be used My first name only be used No name be used

Email Address *

example@example.com

Contact Cell phone number

Please enter a valid phone number. Used for day-of webinar communication.

Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I am a... *

Physical Therapist (PT) Physical Therapist Assistant (PTA) Student Physical Therapist (SPT) Member of the public

To help APTA Pelvic Health identify your photo, please verify the information below:

Race/Ethnic Origin:

American Indian/Alaskan Native Asian/Pacific Islander Hispanic African American/Black White Other

Physical Description *

Tall Average Petite

Hair *

Long Medium Short

Hair Color *

Age *

If you are under 18 years of age, this form must be completed by your parent or legal guardian.

Birth Date *

Month Day Year

Please attach all media files (videos, images) of you that you wish to share with the Academy of Pelvic Health Physical Therapy. *

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Please add any additional comments or anything else we should know. i.e. specific Academy project you are supporting. *

Please check the paragraph below which is applicable to your present situation: *

I am 18 years or 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 knowledgable acceptance of the terms of this release. I am the parent or legal guardian of the child presented in the media files attached. 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.

Individual/Parent/Guardian Full Name *

Individual/Parent/Guardian Signature *

Clear

Date Signed *

Date

By signing and submitting this form, I authorize the Academy to take and use any of my submitted photographs or media in any APTA Pelvic Health publication, production or presentation, including electronic/internet educational or promotional material.

I hereby waive any right to inspect or approve the finished photographs and I waive any right to royalties or other compensation form or related to the use of the submitted media.