MDwise Photo Release and Authorization Form - Adult
By filling out the form below, I certify I am 18 years of age or over, and that I hereby grant to MDwise, its successors and assigns and those acting under its permission or upon its authority, the unqualified right and permission to reproduce, copyright, publish, circulate or otherwise use my name and likeness, in single, multiple, still or moving photographs or in video in which I may be included in whole or part, or composite (a “photo”). I understand and agree that any photo using my likeness will become the property of MDwise and will not be returned.
I acknowledge that my participation with MDwise is voluntary and that I will receive no financial compensation for granting this release or for the reproduction, copyrighting, publishing, circulating or other use of my name and likeness.
I hereby irrevocably authorize MDwise to edit, alter, copy, publish or distribute this photo for purposes of publicizing MDwise’s programs or any other related lawful purposes. I further waive any right to inspect and approve the finished photo or any copy, including any electronic copy, that may be used, or the use to which it may be applied, and I waive any right to royalties or other compensation arising from or related to the use of this photo.
Furthermore, on behalf of myself and my heirs, executors, administrators or assigns, I hereby hold harmless and release MDwise from any and all claims, demands and causes of action that I or my heirs, executors, administrators, or assigns, or any other person acting on my behalf or on behalf of my estate, have or may have by reason of this release and authorization.