Client Consent Release Form

CLIENT CONSENT RELEASE FORM

Client Name:

Service Provider / Company Name:

Effective Date:

WHEREAS

WHEREAS, Client has engaged the Service Provider to perform certain services and acknowledges that the Service Provider may request permission to use Client's name, image, likeness, voice, testimonial or other personally identifying information (collectively, "Client Materials") in connection with marketing, promotional, educational or archival purposes; and

WHEREAS, Client is willing to grant a limited, revocable or irrevocable release and consent to the extent set forth in this Agreement so that Service Provider may use Client Materials in accordance with the terms below; and

WHEREAS, the parties intend that this Consent and Release allocate rights, obligations and consideration between them and provide Client with full disclosure of the scope of use of Client Materials.

CONSENT AND RELEASE

By selecting the options below and signing this form, Client hereby grants to Service Provider a worldwide, non-exclusive, transferable license to use, reproduce, publish, display, distribute and create derivative works of Client Materials, in whole or in part, in any media now known or hereafter devised, for the purposes described in this Agreement and for reasonable ancillary uses.

Use of name, image and likeness for promotional and marketing materials

Release of non-sensitive records, statements, or testimonials

Use of testimonial or interview content

SCOPE OF WORK

PAYMENT TERMS

Client acknowledges that late payments shall incur interest at the following rate: and/or a flat fee of for each missed payment. Invoices are due within days of issuance.

TERM AND TERMINATION

This Consent and Release commences on and, unless earlier terminated in accordance with this Agreement, will continue until .

Either party may terminate this Agreement for convenience upon days' prior written notice to the other party. Termination will not affect the Service Provider's right to continue to use Client Materials already incorporated into materials published prior to the effective date of termination, unless otherwise agreed in writing.

CONFIDENTIALITY

The parties acknowledge that certain information exchanged between them may be confidential. Service Provider shall not disclose Confidential Information of Client except as necessary to exercise rights under this Agreement or as required by law. Confidential Information does not include information that is or becomes generally known to the public through no fault of Service Provider, or information independently developed by Service Provider without use of Client's Confidential Information.

REPRESENTATIONS, WARRANTIES AND INDEMNITY

Client represents and warrants that Client is of legal age to grant the rights herein and has full authority to grant the consent and release provided. Client agrees to indemnify and hold harmless Service Provider from claims, damages or losses arising from Client's breach of any representation or warranty in this Agreement.

GOVERNING LAW

This Agreement is governed by and shall be construed in accordance with the laws of the State of , without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that State for resolution of disputes arising under this Agreement.

ENTIRE AGREEMENT

This Agreement, together with any attachments or written amendments executed by both parties, constitutes the entire agreement between Client and Service Provider with respect to the subject matter hereof and supersedes all prior negotiations, representations or agreements, whether written or oral.

CERTIFICATION AND SIGNATURE

By signing below, Client certifies that Client has read this Consent and Release in its entirety, understands its contents, voluntarily agrees to be bound by its terms and, where applicable, represents that Client has authority to grant the rights and permissions set forth herein.

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