Photo & Video Release Form
I would love to capture client's achievements in photo/video form and consent is warranted to do so. I am looking forward to sharing patient's stories by picture and video to celebrate the time we spend together. The Photo and Video Release Form must be signed due to Ohio Law.

If you have any questions about this form, please contact Tara Helwig Vining by email at or call (330) 536-3042.

Tara Helwig Vining
CEO & Owner of TeleVine Therapy

Email address *
TeleVine Therapy
2187 Golfview Dr NE
New Philadelphia, OH 44663
I hereby allow Tara Helwig Enterprises d.b.a TeleVine Therapy and its affiliates to record and publish photos
and videos (including audio) of me/my minor child or ward for the purpose of promoting TeleVine Therapy and for
documenting and/or reporting events and activities. I understand that this media will be
produced and used for promotional purposes and I authorize TeleVine Therapy to use mine/my child’s or ward’s photograph, video, and/or audio recording on its website and social media
platforms, such as Facebook, Twitter, YouTube, etc., as well as other official printed
publications without further consideration. I also understand that once mine/my child’s or ward’s
image(s) have been captured, that his/her image(s) may be edited, copied, exhibited, published
or distributed and waive the right to inspect or approve the finished product wherein his/her
likeness appears. Additionally, I waive any right to any compensation arising from or related to
the use of his/her image or recording.
There is no time limit on the validity of this release nor is there any geographic limitation
on where these materials may be distributed.
By signing this form I acknowledge that I have completely read and fully understand the
above release and agree to be bound thereby. I hereby release any and all claims against any
person or organization utilizing this material for any authorized purposes.
Patient's Name *
Your answer
Parent/Guardian/Caregiver Information (if applicable)
Parent/Guardian/Caregiver Name (if applicable)
Your answer
Phone Number
Your answer
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