Photograph/Media Consent and Release

Photograph/Media Consent and Release

I hereby consent and authorize an employee or agent of Adams Physical Therapy, Fyzical Therapy & Balance Centers to take photographs or motion pictures of me; or to produce videotapes, audiotapes, closed circuit television programs, web casts, or other types of media productions that capture my name, voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

I authorize Adams Physical Therapy Services, Inc. Fyzical Therapy and Balance Centers to copyright the materials, and I authorize the use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to publications, catalogs, articles, magazines, recruiting brochures, websites or other electronic or otherwise, without notifying me.

I also agree that I am participating on a voluntary basis and I will not receive any payment form Adams Physical Therapy Inc., Fyzical Therapy & Balance Centers. for signing this release or as a result of any publication of the materials.