Imagining Consent Form
Physical Therapist Assistant Program
For good and valuable consideration, I hereby consent and authorize Indian Hills Community College to reproduce,
publish, circulate, and otherwise use for advertising and instructional purposes:
My name and/or signature
Portrait and/or photograph
Videotape/Audiotape
Other imaging
In the following:
Magazines, Newspapers, Rotogravure sections of publications, booklets
Circulars, posters, billboards
Radio and/or television scripts, radio broadcast transcriptions, and/or telecasts
Websites including but not limited to IHCC website, PTA webpage, course webpages
and all other forms of publication or circulation, or any of them in advertising or any other publicity;
and I hereby release said Indian Hills Community College of and from any and all rights, claims, demands, actions,
or suits which I may or can have against it or them on account of the use or publication of said material.
Name:
Signature: Date:
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