3 Dimensional Physical Therapy
Sprouts Open House
Sprouts Contact Form
Parent/Guardian Name:
(Required)
Email:
(Required)
Phone #:
Childs Name:
(Required)
Childs Age:
(Required)
Childs Name:
Childs Age:
Childs Name:
Childs Age:
Would you like to receive additional information from Sprouts?
Yes
No
How did you hear about today's event?
My Childs School/Daycare
A Friend or Family Member
Social Media
Other
Would you like us to follow up with you after today's event?
Yes
No
Do we have permission to use photography/video of your child from today's event?
(Required)
No
Yes
I hereby grant to 3Dimensional Physical Therapy (3DPT) the absolute and irrevocable right and unrestricted permission in respect of photographic portraits, videos, editorial or any pictures 3DPT has taken of me or in which I may be included with others, to copyright the same; to re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs, and in conjunction with any printed matter, in any and all media now or hereafter known, and for any other purpose whatsoever, for illustration, promotion, art, editorial, advertising and trade, or any other purpose whatsoever with restriction as to alteration; from time to time, or reproductions thereof in color, black and white or otherwise made through any media. I hereby waive any rights that I may have to inspect or approve the finished products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless 3DPT, its legal representatives or assigns and all persons acting under its permission or authority, from any liability in connection with the use of the photographs/videographs as aforesaid or by virtue of any alteration, processing or use thereof in composite form, whether intentional or otherwise, as well as any publication or approval rights. I understand that the photographs/videographs taken by 3DPT will be included into stock files. I agree that the photographs/videographs, the transparencies thereof and the rights to copyright the same shall be the sole property of 3DPT, with full right of lawful disposition in any manner. I hereby grant permission to 3DPT to photograph/videograph the minor patient participating in therapy to use the photographs in 3DPT audio-visual and printed materials without compensation or approval rights.
