·      I hereby grant Saugatuck Pediatrics LLC permission to take my (or my child's) photograph or other digital media (“photo”) in any and all of its publications without payment or other consideration.
·      I understand and agree that all photos will become the property of Saugatuck Pediatrics LLC and will become part of my medical record.
·      I hereby irrevocably authorize Saugatuck Pediatrics LLC to take a photo via a camera, iPad or iPhone owned and maintained by Saugatuck Pediatrics LLC for any lawful purpose in my medical care.
·      In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.
·      Additionally, I hereby hold harmless, release, and forever free Saugatuck Pediatrics LLC from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or behalf of my estate have or may have because of this authorization.
 
I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.
 
I ACCEPT: