Photograph Video Release Form printable pdf download

Photograph/Video/Text Release Form

I ___________________________, hereby expressly grant to the Wilson Health Care Center

and Kindley Assisted Living at Asbury Methodist Village and its employees, the right to

photograph me and use my picture, silhouette, and other form of reproduction of the physical

likeness of me, and any text that has been written about me in marketing materials which may

include Asbury Methodist Village web sites and social media channels.

These images will document social events held by Wilson’s and Kindley’s Activities Offices.

These images and text will in no way disclose my medical conditions, show medical care or

therapy or violate privacy rules set by the Health Insurance Portability and Accountability Act

(HIPAA).

I agree not to look to Asbury Methodist Village for any payment of any kind with respect to

making use of the photographs, images, or text without limitation. I agree to hold Asbury

Methodist Village harmless with respect thereto. This release shall be binding upon my agents,

representatives, heirs, assignees, and estate.

I hereby represent that I am over eighteen (18) years of age.

I certify and represent that I have read the foregoing and fully understand the meaning and

effect thereof and, intending to be legally bound, I have hereunto set my hand this ________

day of _______________, 2012.

Signature: _____________________________________________________________

Signature of relative or designated person (as appropriate):

_______________________________________

__________________________

Name

Relationship

Please Print:

Name: ________________________________________________________________

Phone Number: _________________________________________________________

Photo Description: ______________________________________________________

(To be completed by Corporate Communications or designee)

Photograph Video Release Form