Forms - Cirque Lodge Alcohol and Drug Rehab Center

Consent to Release


Contract and Personal Release to:

Cirque Lodge, Inc.
777 N Palisade Drive
Orem, Utah 84097
801-222-9200

From:
Name:
Address:
City, State, Zip:
Phone:

I hereby grant to Cirque Lodge, Inc. and all persons acting through and for them the right to film, photograph, video tape, record, and otherwise use visually and aurally my image, voice, and name, in any manner forever, for promotion, advertising, sales, training, films, music videos, and any other use, in whole or in part, in any and all media, broadcast via the internet, television, motion picture, videotape, DVD, CD, Blu-Ray, or any other media now in use or developed in the future, and waive all rights in connection with such use. I certify that I am over 18 years of age.

On this Date:

Leave this empty:

Forms - Cirque Lodge Alcohol and Drug Rehab Center https://www.cirquelodge.com/Forms
Signature Certificate
Document name: Consent to Release
Unique Document ID: 74dd3805149166b319c494f10941080c16c47ba7
Timestamp Audit
2017-04-12 09:20:04 MDTConsent to Release Uploaded by Matthew Hales - matt@cirquelodge.com IP 205.204.44.102