Photo/Video Release Form

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I,______________________________________  (please print), grant permission to Mobility A.R.C. Network and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release Mobility A.R.C. Network and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation. 

I acknowledge that I am:

[ ] over the age of 18 

[ ] the legal guardian of the following 

If legal guardian of minor(s), please list name(s) here: Name(s): ______________________________________________________________

Signature:_______________________________Date:___________________ Address:_______________________________________________________

Email Address:________________________Phone Number:______________

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