Dixie's Sunrise Massage Therapy

Helping you, help yourself to better health

Release of Liability to use photos and documentation if you agre

 This form is in case you decide to allow me to use your improvements as testimonies and examples of what MediCupping(tm) has done to help you.                          

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 RELEASE OF LIABILITY TO USE PHOTOS AND DOCUMENTATION

In exchange for participation in the MediCupping™ therapy given by Dixie Phillips of Dixie’s Sunrise Massage Therapy, I ____________________________________, agree for myself to the following:

 I agree to allow my image via photo, to be used as an example to my progress of treatment.

 I agree to allow my personal information and data acquired during treatment to be used and viewed on Dixie’s web-site and photo/documentation folder.

I understand I will not be paid in any form for my consent of usage now and any time prior.

I hereby authorize Dixie’s Sunrise Massage Therapy sole and exclusive rights to use, publish, copy, print, copyright or electronically transfer any or all photographs, video, audio clips and documentation taken by me or of me before, during, and after any Dixie’s Sunrise Massage Therapy activity, event or function. 

I also agree Dixie’s Sunrise Massage Therapy may use such photographs, video, documents and audio recordings taken by me or of me with my consent or the use of my name for any lawful purpose, including but not limited to; publicity, illustration, advertising, marketing, copyrighting and Web content.

I hereby irrevocably authorize Dixie’s Sunrise Massage Therapy to edit, alter, copy, exhibit, publish or distribute this media for Dixie’s Sunrise Massage Therapy activities, events, and functions or for any other lawful purpose.

In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears.

Additionally, I waive any right to royalties or other compensation arising or related to the use of any of these photographs, video, or audio clips.

I hereby hold harmless and release and forever discharge the Dixie’s Sunrise Massage Therapy from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 21 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

 

First Name ___________________ Last Name _________________________

 

Date ____________________

 

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