Video Subject Consent Form – Publicity Release
For good and valuable consideration the receipt of which is hereby acknowledged, I irrevocably grant to LF and Associates MD, PC, doing business as Grapevine Health (“Grapevine Health”), an irrevocable, worldwide right and permission to record and use, and publish my name, biographic information, image, voice, performance, photographs, video and/or sound records of my likeness and voice (collectively, “Image”), in any medium or media now known or hereafter devised, throughout the universe, in perpetuity. Grapevine Health shall have the unrestricted right to use my Image in whole or in part, without restriction as to changes, edits, or alterations, through any medium and in any and all media now or later known, and for any purpose, including but not limited to quality improvement, educational, scientific, treatment, research, public relations, marketing, news media, entertainment, informational, commercial and/or charitable purposes. Grapevine Health may freely assign, license, or delegate any of its rights under this Publicity Release without permission, notice, or compensation to me. I hereby waive any right that I as an individual may have to inspect or approve the finished product of any recordings, or any copy or other materials that may be used in connection therewith or the use to which it may be applied. Grapevine Health (and any of its designee(s)) shall own and have the exclusive right to register the copyright in such recordings, my performance, or other related materials, and I will execute any documents necessary to register, record, defend, or protect the Grapevine Health’s rights in same.
I represent that I have the right to make all grants and authorizations hereunder and agree not to assert claims of any nature whatsoever against anyone relating to the exercise of any such grants or authorizations. I hereby forever release, discharge and agree to hold harmless Grapevine Health (and any of its designee(s)), and their respective parents, affiliates, subsidiaries, assigns, and licensees, and their respective employees, vendors, contractors, agents, and legal representatives, from any liability by virtue of the exercise of any grants and authorizations hereunder, including but not limited to any blurring, distortion, optical illusion or use in composite form, whether intentional or otherwise, that may occur in the taking of photographic portraits, pictures or videos, or in any subsequent processing thereof, as well as any publication thereof, including, without limitation, any claims for libel, invasion of privacy, defamation, false light, violation of right of publicity, infringement of copyright, or violation of any other personal or property right.
I warrant that I am of legal age and have the right to contract in my own name and I represent, warrant and covenant that I have not and will not, under any circumstance, use for any reason, or disclose to any person, the identity of any Grapevine Health clients or customers, or the nature of any Grapevine Health engagement or project, disclosed to or learned by me, directly or indirectly, during or through any interaction with Grapevine Health. I have read the above Video Subject Consent Form and Publicity Consent and Release prior to its execution, and I understand and agree to its contents. This Video Subject Consent Form and Publicity Consent and Release shall be binding upon me, my heirs, and assigns. If the person named above is a minor, I warrant that I am the minor’s parent or legal guardian and enter into this Video Subject Consent Form and Publicity Consent and Release on the minor’s behalf as authorized by law.
I consent to receiving SMS text messages from or on behalf of Grapevine Health, including by automated means, at the phone number I have provided. These text messages may contain content of a general health information nature as well as opportunities to participate with Grapevine Health. I also understand that I may be given a choice to interact with content to specify more personalized health information. This information could be used to learn or infer my health status. I have read Grapevine Health’s Privacy Policy and consent to the collection and processing of my information as described in that Privacy Policy. When deciding to interact with content through SMS text messages, Message and data rates may apply. I understand that Grapevine Health cannot guarantee that these communications text messages are fully encrypted, and that such messages could be intercepted or viewed by unauthorized third parties, including visible to others who can view my device screen. I acknowledge that I may opt out of receiving text messages for these purposes at any time by replying STOP to a text message sent by or on behalf of Grapevine Health or by unsubscribing.
Please return to Jogg to agree to these terms.