Release Form

 

I,_________________ do hereby grant to Therapeutic House and its subsidiaries, affiliates, and divisions permission to use my testimonial on my progress of the  treatments provided by Therapeutic House whether in photographic, video, audio or other form, in connection with a video tape, pamphlet, brochure or other medium prepared by or on behalf of Therapeutic House.

I hereby grant all right to usage of my likeness or voice in such videotape, pamphlets, brochures or other mediums to Therapeutic House without any further rights or obligations, and release Therapeutic House and their respective officers, directors, owners, employees and agents, from any and all claims that I may have relating to the use of my likeness or voice in any such videotape, pamphlet, brochure or other medium

 

 

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Print Name                                                                                    Signature

 

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Date