Pain 2 Wellness Center

Media Release Form


 

 

For and in consideration of my engagement as a model by Pain 2 Wellness Center, LLC  hereafter referred to as the photographer/producer, on terms or fee herein stated, I hereby give the photographer / producer, his legal representatives and assigns, those for whom the photographer/producer is acting, and those acting with his permission, or his employees, the right and permission to copyright and/or use, reuse and/or publish, and republish photographic pictures, or portraits of me, recorded images of me, including recordings of my voice, in any medium, including motion picture and video images, in which I may be distorted in character, or form, in conjunction with my own or a fictitious name, on reproductions thereof in color, or black and white made through any media by the photographer at his studio or elsewhere, for any purpose whatsoever: including the use of any printed matter in conjunction therewith.

 

I hereby waive any and all claims, including those under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and release the Pain 2

Wellness Center, LLC and its agents, employees, officers, directors and assigns from any and all liability in connection with the taking and use of my image, and on behalf of myself, my heirs and assigns, waive any and all rights of privacy and/or claims for damages or injuries sustained by me or my property in connection with the taking and use of my image.

 

I hereby waive any right to inspect or approve the finished photograph, motion picture, videotape, advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that it might be applied.

 

I hereby release, discharge and agree to save harmless the photographer, his representatives, assigns, employees or any person or persons, corporation or corporations, acting under his permission or authority, or any person, persons, corporation or corporations, for whom he might be acting, including any firm publishing and or distributing the finished product, in whole or in part, from and against any liability as a result of any distortion, blurring, or alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in the taking, recording, processing, editing or reproduction of the finished product, its publication or distribution of the same, even should the same subject me, the designated property, to ridicule, scandal, reproach, scorn or indignity.

 

 

 I hereby warrant that I am over/under 21 years of age and competent to contract in my own name insofar as the above is concerned.

I have read the foregoing release, authorization and agreement, before affixing my signature below, and warrant that I fully understand the contents thereof and am signing below voluntarily.

 

Dated:                        

Address:                

Telephone:   

 

I hereby certify that I am the parent and/or guardian of and hereby consent that any photographs, images or recordings which have been or are about to be taken by the photographer / producer may be used by him for the purposes set forth in the original release herein above with the same force and effect as if executed by me.                                           

Dated:

 

Address :

Leave this empty:

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Signed by Winston Carhee
Signed On: September 24, 2021


Signature Certificate
Document name: Media Release Form
lock iconUnique Document ID: 2e40395be8ea2cf95d6883ce67f4403feeeaaa3a
Timestamp Audit
September 24, 2021 10:00 am ESTMedia Release Form Uploaded by Winston Carhee - winston@carhee.com IP 98.251.30.4