I hereby authorize Grace Medical Home, Inc., to take, reproduce, and use my image and statements in photographs, video, voice recordings, and quotations, in whole or in part, in connection with the production of programs or materials about Grace Medical Home, Inc.

 

I release Grace Medical Home, Inc., the crew involved in media capture, their offices, and employees from liability for any violation of any personal or proprietary right I may have in connection with such use.

I understand this includes educational and marketing materials distributed in any and all formats. I disclaim any rights to such media in perpetuity.

 

I am 18 years of age or older, and have read, understand, and agree to all the foregoing provisions.

 

For those under the age of 18, a parent or legal guardian consents to the taking and use of the photographs and releases Grace Medical Home, Inc. from any liability in connection with them.