By checking this box and submitting this Publicity Release Form (“Authorization”), I hereby grant permission to Renewal Christian Counseling Center and any affiliated representatives (RENEWAL), the right and license to use my name, any comments I voluntarily included in the Testimonial section below (“Testimonial”) for marketing purposes in connection with the websites, social media, print, and other advertising, marketing, informational and educational publications for RENEWAL, or any other publication RENEWAL may deem useful and appropriate, including electronic and print media (i.e. video, pamphlets, mailings, etc.) and I expressly authorize the RENEWAL to disclose my Photos and Testimonial (together, my “Materials”) in the foregoing materials. I understand that this means that my Materials may be disclosed to any person viewing the websites or advertising, marketing, informational, educational or other publications. Preferences for sharable information speci ed on reverse. I understand RENEWAL may paraphrase and edit any verbal/written communication (quotes, comments, testimonial, etc.) provided by me. I acknowledge RENEWAL may edit, alter, and enhance photo/video of me for publication.
I agree and confirm that I am providing this Authorization and any Materials to RENEWAL voluntarily and without any expectation of receiving compensation of any kind in exchange. I hereby confirm that no one has made any offer, promise or representation of compensation of any kind to me in exchange for my Authorization and my Materials.
I represent that I am of legal age, or if the patient is a minor, that I am the parent or legal guardian of the patient. I further represent that my Testimonial (if any) is truthful and accurate. I am aware that I am consenting the authority of RENEWAL to use my physical and verbal image for promotional use of the organization, and release them from any claims and liability to said copy.