Media Release Form

Media Release Form
Client Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I, First Name* Last Name* grant permission to Suncoast Mental Health Center, hereinafter known as the "Media" to use my image (photographs and/or video) for use in media publications including:
Check All That Apply*

VideoEmail BlastsPrinted MaterailsWebsiteSocial Media Plateforms
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.
Please initial the paragraph below which is applicable to your present situation:
- I am 18 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.
Name of parent or legal guardian:

(if under 18 years of age)
Name

First NameLast Name
Signature of parent or legal guardian: (if under 18 years of age)

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Signature of Adult

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Should be Empty:

Media Release Form

Name of parent or legal guardian: