Photo Consent Form

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I,______________________________________________ , for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, do hereby grant to Lehigh Valley Senior Care, LLC, d.b.a. Home Instead Senior Care® and Home Instead, Inc., and their respective representatives, officers, directors, employees, contractors, agents, successors, licensees, and assigns (collectively "Home Instead") permission and authorization to take or use photographs and videos of me, make recordings of my voice, interview me, and obtain accounts of my spoken and written thoughts and biographical information (hereinafter, collectively, the "Images and Accounts").

I further hereby irrevocably grant Home Instead permission and authorization to use any or all of the Images and Accounts, in complete or partial form, in connection with any works that Home Instead may create. Home Instead's use of any of the Images and Accounts may include reproduction, distribution, modification, and display, and may be in composite or modified form and in any media format now known or hereafter developed, including, but not limited to, books, publications, video, the Internet, and the World Wide Web. The use may also be in advertising or promotional materials.

I hereby waive any right to approve of the use of or inspect any of the Images and Accounts and any written copy that may be created and appear in connection therewith, and I acknowledge and understand that Home Instead is under no obligation whatsoever to utilize any of the rights granted under this Authorization and Release.

I hereby agree to be responsible for any loss or damage that Home Instead may suffer or incur by reason of the use of any of the Images and Accounts and/or my name or any fictional name or written copy in connection therewith.

I hereby acknowledge that Home Instead is using the Images and Accounts in reliance upon this Authorization and Release. I further acknowledge and agree that this Authorization and Release shall be binding on me, my legal representatives, heirs and assigns.

I certify that I am 18 years of age or older and competent to sign this Authorization and Release, that I have voluntarily signed this Authorization and Release, and that I have read and fully understand the meaning and effect thereof.

Dated: _______________________              Signature: ____________________________________

Printed Name: ______________________________


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