Dubin Center Consent Form
Brushstrokes from the Soul
Photo and Art Consent
I also hereby authorize and consent that The Dubin Center, shall have the absolute right to copyright, publish, use, sell or assign any and all artwork, photographic portraits or pictures, television spots, movie films, videotapes and/or sound recordings, or any part thereof, they have taken or made of me on this date or in which I may be included, name or other biographical data, in whole or part, whether apart from or in connection with, illustrative or written printed matter, story or news item, motion pictures, internet usage, television or radio spots, or for publicity, advertising or any other lawful purpose whatsoever, in conjunction with my own or a fictitious name, or my real or fictitious biographical data, or in reproduction thereof in color or otherwise in any media now known or hereby created.
Art, Photo and/or video consent given I understand that I have the right to amend, revoke, modify, or change this release at any time, and that any changes must be in writing.
Please do not list the name of the artist (resident/loved one) in any promotional materials.
Name
First Name
Last Name
Short Bio of Artist
Name of facility
Date
Signature
Clear
Submit
Should be Empty: