Testimonial Release


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2401 PGA Blvd, Suite 128 Palm Beach Gardens, FL 33410

TESTIMONIAL RELEASE FORM

www.HearPalmBeach.com [email protected] (561) 500-EARS

I hereby grant to Palm Beach Hearing Associates, LLC and any of its divisions, subsidiaries, or affiliated companies, the irrevocable and unrestricted right to use, publish, and reproduce, in whole or in part, and in full or as subsequently edited, any photographs, video, audio, or audio-­visual representations of me taken by employees, agents, or contractors of Palm Beach Hearing Associates, LLC, for library publications, electronic reproductions, commercial, promotional, or training materials, websites, social media sites or any other purpose. Palm Beach Hearing Associates, LLC may disclose my city and state of residence (not a street address, building, phone number, or email address), and with respect to my name, Palm Beach Hearing Associates, LLC may disclose only my first name and the initial of my last name. I hereby attest that I am authorized to sign this release. I understand that Palm Beach Hearing Associates, LLC retains ownership of all such photographs, videos, audio, or images derived from same, and I grant my permission to Palm Beach Hearing Associates, LLC to alter or edit the same without restriction and to copyright the same or any partial, full, or edited reproduction or derivation of the same. I hereby release the photographer/videographer and Palm Beach Hearing Associates, LLC from all claims and liability relating to use, publication, reproduction, or dissemination of said photographs, video, audio, or images. Name of person appearing in video/photo/audio: Printed Name:

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(if 18 Years or older)

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Parent or Guardian must sign if individual is under 18 years of age. Printed Name of Parent/Guardian if applicable:



Signature: Parent/Guardian if applicable



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