Individual Release & Consent Form - Harmonious Life Systems

1024 E. Willow Grove Ave. Wyndmoor, PA

PH: 215-948-9124 Email: [email protected]

Individual Release & Consent Form for Publication of Photography, Voice & Image

HLS, LLC. uses this form to request individuals' permission to be photographed, filmed, or voiced recorded during one or more activities of HLS, LLC. The consent to the use of individuals images is intended to extend only HLS, LLC and not to be assigned to any other entity without the consent of the individual or individual's caregiver. These materials may include, but are not limited to, brochures, video/audio broadcast and/or tapes; digital or otherwise, any printed or electronic publications; agency newsletters, the agency website, and/or any other promotional materials, etc. Individuals and families have the right to rescind consent at any time.

Please check one of the boxes below based on your preference:

I give my consent to have my picture/image taken, voice recorded and my picture and voice used along with my name and picture/image to represent the services of HLS, LLC related to its promotional materials that include, but are not limited to, brochures, video/audio broadcast and/or tapes; digital or otherwise, any printed or electronic publications; agency newsletters, the agency website, and/or any other promotional materials, etc.

I give my consent, but my permission is needed each time to have my picture/image taken, voice recorded and my picture and voice used along with my name and picture/image to represent the services of HLS, LLC related to its promotional materials that include, but are not limited to, brochures, video/audio broadcast and/or tapes; digital or otherwise, any printed or electronic publications; agency newsletters, the agency website, and/or any other promotional materials, etc.

I Do Not give my consent to have my picture/image taken, voice recorded and my picture and voice used along with my name and picture/image to represent the services of HLS, LLC related to its promotional materials that include, but are not limited to, brochures, video/audio broadcast and/or tapes; digital or otherwise, any printed or electronic publications; agency newsletters, the agency website, and/or any other promotional materials, etc.

Individual Name:

Signature of Individual: (If able to sign)

Date:

Expiration Date: