Medical/Photo RELEASE FORM I, the undersigned, do hereby grant

Medical/Photo RELEASE FORM
I, the undersigned, do hereby grant permission to the Next Generation Physical Therapy to use the
image of my child or myself, ________________________________. Such use includes the display or
use of photographs taken of my child or myself for use in materials that include, but may not be
limited to, printed materials such as brochures and newsletters, and digital images such as those on
the Next Generation web site.
I give unrestricted permission for my child or my self’s image to be used in print and digital media. I
agree that these images may be used by the Next Generation Physical Therapy for a variety of
purposes and that these images may be used without further notifying me. I do understand that the
child will not be identified in conjunction with any images.
I, the undersigned, do hereby grant permission to allow Next Generation Physical Therapy to consult
with any Athletic Trainers or Coach’s listed below about treatment.
_____
Jason Cates
_____
Lyndsey Rich
_____
Holly Whitaker
_____
Jennifer Asbury
Coach’s ____________________________________________________________________________
Coach’s ____________________________________________________________________________
Parent/individual signature ______________________________________ Date ___________________