I, , grant Total Education Solutions Inc., dba TES Therapy (“TES Therapy”) and its employees, officers, agents, and assigns (the “Released Parties”) permission to use my or my child’s voice, image, and likeness, in any television broadcast, photograph, video, internet site, audio-recording, and in any and all of its publications, including website entries (collectively, “Promotional Materials”) without payment or any other consideration, save for the consideration of having the opportunity to represent TES Therapy in its promotional materials as described above.
I understand and agree that the Promotional Materials will become the property of TES Therapy and will not be returned. I hereby irrevocably authorize TES Therapy to edit, alter, copy, exhibit, publish, adapt, perform, reproduce, modify, make derivative works, distribute or otherwise use my voice, image or likeness for purposes of publicizing or promoting TES Therapy’s products and services or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my voice, image or likeness appears. Additionally, I waive any right to royalties or other compensation arising from or related to the use of the Promotional Materials. TES Therapy may exercise any of these rights itself or through any successors or assigns.
I relinquish and give to the Released Parties all right, title, and interest that I may have in the Promotional Materials. I may be included in the Promotional Materials in whole or in part, in composite or distorted form, or in reproductions thereof, in color or otherwise, with or without my name, made and published through any medium including, but not limited to, any printed medium, video, and/or on the internet.
I hereby hold harmless, release, and forever discharge TES Therapy, its successors and assigns from all claims, demands, and causes of action that I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf, or on behalf of my estate, have or may have by reason of this authorization.
I understand that my records are protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may re-disclose the information and it may no longer be protected by the HIPAA privacy law.
This consent authorizes both any initial and any subsequent publication or disclosure of the Promotional Materials, with or without my identity, at any time. I understand that I may revoke this authorization at any time; however, I also understand that once such materials are in the public domain it is virtually impossible to retrieve and erase them. While TES Therapy will no longer continue to publish the Promotional Materials following my revocation, I understand that my permission granted now means Promotional Materials will stay in the public domain indefinitely.
I understand that the covered entity seeking this authorization is not conditioning treatment, payment, enrollment or eligibility for benefits on whether I sign the authorization.
I understand that the terms herein are contractual and not a mere recital, that this instrument is legally binding, and that I have voluntarily signed this document.
I understand that I am entitled to receive a copy of this authorization after it is signed.