BIRTHOLA, INC. VISUAL MEDIA CONSENT

PRIVACY RIGHTS AND USE OF INFORMATION

Person/Organization (required)


CAPTURED IN VISUAL MEDIA

I give Birthola, Inc.(Birthola) permission to make photo graphs, videotapes, films or other likenesses of me, my child or legal ward. I hereby grant to Birthola the unrestricted right to copyright any of the above mentioned materials containing images of me, as well as the unrestricted right to use and reuse them, with their caption information, in whole or in part, in any manner, for any purpose and in any
medium now known or hereinafter invented. These rights include, but are not limited to, the right to publish, copy, distribute, alter, license and publicly display these materials and images for editorial, trade, marketing, and/or advertising purposes. I also grant to Birthola and its licensees the unrestricted right to use and disclose my name in connection with use of the above materials.

I understand and agree that I will not be paid for any use described.

I also waive, and release and discharge Saundra’s Partnership Center, Birthola, Inc. its officers, employees and/or agents from, any and all claims arising out of or in connection with any use of the materials, caption information and images described above, including any and all claims for libel defamation and/or invasion of privacy or publicity. I realize I cannot withdraw my consent after I sign this form and I realize this form is binding on me and my heirs, legal representatives and assigns.

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IF THE ABOVE PERSON IS UNDER 18 YEARS OF AGE THE LEGALLY RESPONSIBLE CARE PROVIDER, A PARENT, OR LEGAL GUARDIAN MUST COMPLETE THE FOLLOWING:

I have care responsibility and the authority to approve this consent:

for the person(s) named above and I hereby sign this consent form on behalf of such person(s) in accordance with the statement above.

Parent/Legal Guardian/Caretaker

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