Media Release Waiver

Media Release Waiver

Photo, Video & Personal Story
Today's Date

MonthDayYear
Date
Your Age
Your Full Legal Name

First NameLast Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
I grant permission for Lindsay Brooke and Brainiac Wellness to use my:

VoiceImageVideoWritten Testimonial/and or Personal StoryOther
The Media obtained shall be used for promotional materials, including but not limited to:
- Social media platforms
- Websites
- Marketing emails
- Advertisements
- Educational content
- Books, blogs and digital publications

I understand and agree that:
- I will not receive financial compensation for the use of my media or personal story.
- Brainiac Wellness reserves the right to edit and distribute my media as needed for branding, educational, and promotional purposes.
- My participation is voluntary, and I may revoke consent in writing at any time.
- If I choose to revoke consent after publication, Brainiac Wellness will make reasonable efforts to remove future usage but cannot retract previously published materials.
Optional: Personal Story Release
(Check one option below)

I agree to allow my personal story/testimonial to be shared publicly (with my first name, initials or anonymously as indicated below)I do not consent to sharing my personal story/testimonial, but I allow my photo/video to be used.I do not consent to sharing my image, video, or personal story in any form.Type option 4
If sharing my personal story/testimonial, I prefer:

My full name to be usedOnly my initials to be usedMy story to be shared anonymously
Agreed and Accepted by
Name of Releasee

First NameLast Name
Date

MonthDayYear
Date
Signature of Releasor or Releasor's Guardian

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Agreed and Accepted by