Pathways Model Release

Model Release

I hereby give permission to Pathways to Family Wellness Magazine, and its publisher the ICPA, Inc., to use my name and photographic likeness and/or the name and photographic likeness of my child/children whom I name below.

Question Title

Name (Required.)

First

Last

Question Title

Address (Required.)

Street Address

Address Line 2

City / Town

State / Province / Region

Postal / ZIP Code

Country

*Email *

Question Title

Chiropractor's Name

Question Title

Child's Name

First

Last

Question Title

Child's Name

First

Last

Question Title

Child's Name

First

Last

Question Title

Child's Name

First

Last

Question Title

Child's Name

First

Last

Question Title

Digital Signature (Required.)

By checking this box and clicking Submit, I give permission to Pathways to Family Wellness Magazine, and its publisher the ICPA, Inc., to use photos containing the photographic likeness of the above models, for print, web or digital reproduction, and for commercial and/or editorial use, including (but not limited to) advertising/promotion via social media, newsletters, and/or printer material relevant to Pathways magazine and ICPA, Inc.

Pathways Model Release

Model Release

Question Title

* Name (Required.)

Question Title

* Address (Required.)

Question Title

* Chiropractor's Name

Question Title

* Child's Name

Question Title

* Child's Name

Question Title

* Child's Name

Question Title

* Child's Name

Question Title

* Child's Name

Question Title

* Digital Signature (Required.)

Name (Required.)

Address (Required.)

Chiropractor's Name

Child's Name

Child's Name

Child's Name

Child's Name

Child's Name

Digital Signature (Required.)