Release Form
PROGRAM TITLE: Share Your experiences
PRODUCER’S NAME: The Clinician Exchange, Inc.
PRODUCER’S PHONE NUMBER: 1-800-4-the-clinx
For valuable consideration received, I, the below named person being eighteen years or older, or the parent or legal guardian of the minor named below (hereinafter referred to as “I” or “myself”), hereby acknowledge and agree as follows:
- Consent to Record Images and Use Name, Likeness and Biographical Information. I hereby grant to TCX and their licensees, successors and assigns to TCX the right to photograph, audio-visually record or otherwise digitally collect the undersigned Participant’s likeness and any presentation provided by the undersigned in connection with the Webinar identified herein (collectively “Digital Images”). I authorize TXC to use the name and brief biographical information of the undersigned Participant in connection with the Digital Images.
- License. I hereby grant to TCX a non-exclusive, perpetual, worldwide, non-revocable, royalty-free license to use, reproduce, distribute, create derivative works of, publicly perform, and publicly display the Podcast, and all Digital Images collected, in whole or in part, in all forms of media, whether now known or later discovered, for any purpose whatsoever.
- Waiver, Release and Hold Harmless. I hereby waive any right to inspect or approve the finished product, including written copy or edited audiovisual recording wherein the undersigned Participant’s likeness or presentation appears. I hereby waive any right to control the use of the Digital Images in whatever media used and waive any right to royalties or other compensation arising from or related to the use of the Digital Images. I hereby release and hold harmless TCX from and against any claims, damage, loss, liability, cost or expense (including without limitation attorneys’ fees and costs) arising out of or related to TCX’s use of the Digital Images.
Full Name of Participant
Full Street Address
Telephone
Date of Birth
Date
Signature: