Photo Release Form (Minors)

Photo Release Form for Minors (if under 18)

I (legal parent or legal guardian) grant KICKSTART ORTHOTICS & PROSTHETICS, LLC my permission to use my/my child's photographs for educational web content and to promote KICKSTART O&P. I understand that the images may be used in print publications, online publications, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Child Patient Name

Describe Photograph/s (Ex. brace fitting)

Phone Number

Parent/Guardian Name

Parent/Guardian Signature

KickStart
ORTHOTICS & PROSTHETICS

Photo Release Form for Minors (if under 18)

KickStart Orthotics & Prosthetics, LLC

KickStart ORTHOTICS & PROSTHETICS

Photo Release Form for Minors (if under 18)

KickStart
ORTHOTICS & PROSTHETICS