Consent Form

Help us share your successes.

Please complete the consent form below.

Name *

First

Last

Address *

City, State *

Zip/Postal Code *

Email *

Phone Number *

Today's Date *

Type of Consent *

Written Testimonial
Photo
Video
All of the above

I understand any written and/or video testimonial, and/or photo of me (the “Testimonial”) and made on behalf of Columbus Fitness Consultants (hereinafter called “The Business”) may be used in connection with publicizing and promoting The Business. I authorize The Business to use my name, brief biographical information, and the written and/or video Testimonial, and/or photo as defined on this form by me. I hereby irrevocably authorize The Business to copy, exhibit, publish or distribute the written and/or video Testimonial, and/or photo for purposes of publicizing The Business’ programs and services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites, social media, or in any other distribution media. I agree that I will make no monetary or other claims against The Business for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including a written copy or edited video wherein my likeness or my testimonial appears. I hereby hold harmless and release The Business from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I have read the authorization and release information and give my consent for the use as indicated above.

Signature *

Please type your first and last name here along with today's date as your Electronic Signature. Example: Jane Doe 7/25/2012