American Society of Hand Therapists - California Chapter

Model release form

I _________________________ , grant permission to ASHT-Ca Chapter and its board to use photographs taken of me or my family on the date and at the location listed below for the use of ASHT Hand Therapy Awareness and Injury prevention week promotion and on the ASHT-Ca.org website. No personal information about the model will be published in any format.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs.

I hereby agree to release, defend and hold harmless ASHT-Ca chapter and its board from and against any claims, damages or liabilities arising from or related to the use of the photographs, including but not limited to any misuse distortion blurring alteration, optical illusion or use in composite form either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I am 18 years of age or older and I am competent in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release before signing below and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

Location of Photo: __________________________________________________

Date: _____________________________________________

Name (Please print): ________________________________

Signature: _________________________________________

(Signature of Guardian): If under 18 years of age