AI WELLNESS CENTER OF EXCELLENCE

PHOTO & VIDEO RELEASE FORM

Location: AI Wellness Center of Excellence – 2080 Century Park East, Los Angeles, CA 90067

PHOTO & VIDEO RELEASE FORM

PARTICIPANT INFORMATION

Name
Name
First Name
Last Name
Address
Address
Street Address
Apartment/Unit Number
City
State/Province
Zip/Postal

CONSENT & RELEASE

I,  hereby grant permission to AI Wellness Health Management, Inc., its affiliates, subsidiaries, agents, licensees, contractors, successors, and assigns (collectively, “AI Wellness”) to record, photograph, videotape, and/or interview me during my visit, participation, or appearance at the AI Wellness Center of Excellence and any associated events, including but not limited to the 90-Day Pilot Program, film recordings, Voice of Evidence Podcasts, social media interviews, and promotional productions.

I understand and agree that:

  1. Ownership & Use: All photographs, audio, video recordings, and other media containing my image, likeness, voice, statements, or participation (collectively, “Media”) shall be the exclusive property of AI Wellness.
  2. Purpose of Use: AI Wellness may use the Media for promotional, educational, documentary, advertising, or commercial purposes, including but not limited to:
    • Websites, social media, films, and streaming platforms
    • Training and educational materials
    • Print or digital marketing, press releases, or exhibitions
  3. Compensation: I acknowledge that I will not receive any financial compensation for the use of the Media now or in the future.
  4. Right to Edit: AI Wellness retains full editorial control over the use and modification of the Media.
  5. Release of Liability: I hereby release and hold harmless AI Wellness, its officers, employees, contractors, and partners from any and all claims, demands, or causes of action arising out of or connected with the use of said Media, including but not limited to claims for defamation, invasion of privacy, or rights of publicity.

Revocation: This consent is irrevocable, worldwide, perpetual, and may only be withdrawn in writing for future unpublished use.