Media Release - Employee | Holistic Health Associates

HHA Employee Media Release Form
Name*
First Last
Consent YES
By signing below, I consent and authorize Holistic Health Associates to copyright, use and publish any of the images or media in any format taken of me. I understand these images may be used for a variety of purposes and may appear on Holistic Health Associates website, newsletter, promotional materials or any other media now known or to be invented. I also understand that Holistic Health Associates or any entity authorized by Holistic Health Associates, will use the images and/or media exclusively for purposes relating to Holistic Health Associates and not for any commercial gain. These images will never be sold or released to a third party.

By signing below, I acknowledge and understand the vulnerability and accessibility of images and information on the internet and printed materials; including but not limited to downloading images from the internet or make copies from printed materials. I agree that Holistic Health Associates is not responsible for unauthorized use of the images or media. I am aware that I am not entitled to any compensation or other consideration for the use of these images.

By signing below, I acknowledge I have read and understand this release. I affirm that I am at least 18 years of age, or, if I am under 18 years of age, I have obtained the required consent of my parents/guardians as evidenced by their signature below.

By signing below, I confirm that any changes to the status of this consent is my responsibility and must be submitted to the Marketing & Sales Director by submission of an update Employee Media Release Form. Any marketing activity including my likeness before submission of the updated form will be follow the previously submitted form consent.
Consent NO
By selecting this box and signing below, I DO NOT consent and authorize Holistic Health Associates to copyright, use and publish any of the images or media in any format taken of me. I understand that by opting out, I will not be included in any group photos and any materials used for all marketing efforts, including but not limited to social media, the HHA website, or publications we are featured in.

By selecting this box and signing below, I confirm that I will abstain from participating in group photos and/or videos taken by a member of Management as well as photos or videos that will be used to share events or occasions that take place as a result of working for Holistic Health Associates and would likely be shared on social media. This includes but is not limited to Holistic Health Associates events, staff appreciation from patients, holiday photos, and other announcements.
Signature of Employee, Legal Representative, or Parent/Guardian*
By completing this box, you have digitally signed the Holistic Health Associates Media Release Form. If staff member is under the age of 18, a parent or Legal Guardian MUST sign this form.
Your Name
Your Name
Your Name
Date*
Month
Day
Year
Printed Name of Employee, Legal Representative, or Parent/Guardian
Relationship to Employee
- Employee
- Parent/Guardian

HHA Employee Media Release Form