MULTIMEDIA AGREEMENT

MULTIMEDIA AGREEMENT

I hereby grant LifeWise StL, its representatives, and assignees the right to take and use photographs, video recordings, audio recordings, and/or digital images of me.

I understand that these images may be used for promotional purposes, including but not limited to
- Social media posts
- Website content
- Brochures and flyers
- Advertisements and marketing materials
I acknowledge the following:
1. Voluntary Participation: My consent is not required in order to access services.
2. HIPAA Protections: This release does not apply to any photographs, video recordings, audio recordings, or digital images captured in a confidential setting, including but not limited to therapy sessions or any other interactions involving Protected Health Information (PHI) as defined by HIPAA.
3. No Compensation: I understand that I will not receive any compensation for the use of these images.
4. Rights Granted: I grant full rights to LifeWise StL to use, publish, reproduce, copyright, and distribute the images in any format without restriction.
5. Revocation of Rights: I understand that I can revoke this permission at any time by providing written notice to LifeWise StL but that revocation will not affect any uses made prior to receipt of the notice.
I have read this release and understood its contents.
Do you agree to these terms?
Full Name of LifeWise Participant
First & Last Name
Participant Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Which of the following best describes the signer?
Signature
Parent/Guardian Full Name
First & Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
---- Please do NOT fill out anything below this line ----

By typing your name below, you - as a LifeWise StL staff person or authorized representative - attest that you have explained the form in full to the participant or their parent/guardian and answered all questions.
Staff Name
First & Last Name
Upload Signed Copy if Completed on Paper

Staff are still required to answer all fields above to reflect attached form
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