Skip to main content

Media Release Form

Rocket Seperator, Celestial Dental | General Dentist
1 Step 1

Microsoft Word - Media Recording Release Form.docx

I, the undersigned, do hereby consent and agree that Celestial Dental, its employees, or agents have the right to take photographs, videotape, or digital (audio) recordings of me and to use these in any and all media, now or hereafter known, and for any marketing communication purposes. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I do hereby release to Celestial Dental, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I also grant creative permission to alter any media recordings of me.

I understand there will be no financial or other remuneration for recording me, either for initial or subsequent transmission/playback.

I also understand that Celestial Dental is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. If not of age, my parent or guardian understands this on my behalf.

I am a parent/guardian signing on behalf of the individual above.