Consent & Likeness

Effective on the date of signature, approval for past use and permission for present and future use is being granted to Buffalo Rehab Group, Physical Therapy PC of 2100 Union Road, West Seneca, New York, 14224, to any video, picture, or testimony (termed “the media”) authorized by the signed party.

Permission is being given by the undersigned party, as more fully explained in this Consent and Release. The undersigned is an adult and fully authorized to sign this Consent and Release.

For valuable consideration, receipt of which is hereby acknowledged, the undersigned hereby grants to Buffalo Rehab Group Physical Therapy, PC its agents, employees, licensees, and successors in interest (collectively, the “Released Party”) all ownership rights and the absolute and irrevocable right and permission to copyright, use and publish “the media” obtained pursuant to this Consent and Release.

The Likeness may be copyrighted, used, and/or published individually or in conjunction with other photography or video works, and in any medium (including without limitation, print publications, public broadcast, website, social media, etc) and for any lawful purpose, including without limitation, trade, exhibition, illustration, promotion, publicity, advertising and electronic
publication.

The signed individual represents and warrants that no other party has been granted an exclusive license with respect to “the media”, and (ii) no other party’s authorization or consent is required with respect to the permission granted to the Released Party under this Consent and Release.

The signed individual releases the Released Party (and all persons acting under its permission or authority) from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to the Likeness (collectively, “Claims”).

This release includes without limitation any Claims related to blurring, distortion, alteration, optical illusion, digital alteration, use in composite form, whether intentional or otherwise, or use of a fictitious name, that may occur or be produced in the processing or publication of the Likeness.