MDwise Photo Release and Authorization Form - Child
By filling out the form below, I certify I am 21 years of age or over, that I am the parent or guardian of the minor child named below (“child”), 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 child’s name and likeness, in single, multiple, still or moving photographs or in video in which my child may be included in whole or part, or composite (a “photo”) . I understand and agree that any photo using my child’s likeness will become the property of MDwise and will not be returned.
I acknowledge that my and my child’s participation with MDwise is voluntary and that neither I nor my child will receive any financial compensation for granting this release or for the reproduction, copyrighting, publishing, circulating or other use of my name or my child’s name and likeness.
I hereby irrevocably authorize MDwise to edit, alter, copy, publish or distribute this photo of my child 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 of my child or any copy, including any electronic copy, that may be used, or the use to which it may be applied, and I waive for myself and my child any right to royalties or other compensation arising from or related to the use of this photo of my child.
Furthermore, on behalf of my child and myself, and our respective heirs, executors, administrators, or assigns, I hereby hold harmless and release MDwise from any and all claims, demands, and causes of action that I, my child, or our respective heirs, executors, administrators, or assigns, or any other person acting on my behalf, my child’s behalf, or on behalf of my or my child’s estate, have or may have by reason of this release and authorization.