CNS / Cincinnati Neuro-rehabilitation Services Inc.
Speech Language Therapy
Pre-Registration
Medical Release
HIPAA
Photo Release
Photo Release

 CNS   Cincinnati Neuro-rehabilitation Services, Inc.      speech-language pathologists

   10133 Springfield Pike, Suite D    ·    Cincinnati, OH  45215    ·     513/821-0110    ·    Fax 513/821-0757

 

Release Form for Media Recording

I, the undersigned, do hereby consent and agree that Cincinnati Neuro-rehabilitation Services, Inc., its employees, or agents have the right to take photographs, videotape, or digital recordings of ____________________________________________  and to use these in any and all media, now or hereafter known, and exclusively for the purpose of marketing. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I do hereby release to Cincinnati Neuro-rehabilitation Services, Inc., its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.

I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

I also understand that Cincinnati Neuro-rehabilitation Services, Inc. is not responsible for any expense or liability incurred as a result of my participation in this recording.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

 

 

Name

 

 

 

Address

 

 

 

Phone

 

 

 

Witness for the undersigned

 

 

 

Signature  (Parent/Guardian Signature if subject is under 18 years of age)

Date

 



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