Photo Release Form Photo Release Form

Minor Photo Release

The undersigned hereby gives his/her consent and consents on behalf of the minor(s) listed below (whether one or more, the “Minor”) to the use of the Minor’s name, likeness, image, and/or other identifying materials by Kaldas Center for Fertility, Surgery & Pregnancy, S.C., a Wisconsin service corporationand its affiliates, officers, agents, employees, successors and assigns (collectively, “Releasee”).

With this Release, Releasee is granted permission to use, re-use, publish, and re-publish photographs, portraits, pictures, images, and other identifying indicia of the Minor or in which the Minor may be included, in whole or in part, in complete, partial, or composite form, without restriction as to changes or alterations, in color or otherwise, made through any medium now or hereafter known, alone or in conjunction with any wording including the Minor’s actual name or a fictitious name. Releasee is authorized to use the image, likeness, name, and/or other identifying indicia of the Minor for purposes of advertising, publicity, trade, display, exhibition, and any other commercial, business or other purpose. The undersigned and the Minor understand and agree that no compensation will be paid for such use or subsequent re-use.

I and the Minor hereby release and discharge Releasee from any and all claims and demands arising out of or in connection with the use of the photographs, including without limitation any and all claims for libel or invasion of privacy or by virtue of blurring, distortion, alteration, optical illusion or use in composite form, whether intentional or otherwise, that may occur or be produced in the capturing of images or in any subsequent processing thereof, as well as any publication thereof. I and the Minor hereby waive any right that either of us may have to inspect or approve the finished product or 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 acknowledge that I have read the foregoing; fully understand the contents; agree to the terms on behalf of myself and the Minor, without reservation; and warrant that I am at least eighteen years of age, have the right to contract and consent on behalf of the Minor, and am competent and capable of giving consent. This release shall be binding on the undersigned and the Minor and their heirs, legal representatives, and assigns.

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