Audio-Video Release Form | Jan Luther, Tapping and Coaching for Spiritual Healing

Thanks so much for wanting to share your experiences and testimonies with others!

We know it will be a great benefit to those who see, hear and read what you have to share.

Please take a minute to give us your permission to do this by filling out our release form. (In the past, we have obtained permission to do this using emails, but we’ve found that having a single form is more efficient and easier to manage.)

Please know that all of the “legal speak” in the sections below is not intended to intimidate, but to make sure you know how we intend to use your video, audio and/or transcript. It also makes sure that we follow our processes of ensuring that we have your permission before ever sharing your audio, video or transcription with others.

Audio-Video Release Form

First Name *

Last Name *

Email Address *

Address *

Address

City

State/Province

Zip/Postal

Country

Please copy the date and topic in the email you received and paste that information into this field. *

By providing my name and signature through the use of this online release form, I hereby grant permission to Jan Luther and The Rejuvenation Station LLC and its assigns, the rights of my image, in video or still, and the likeness and sound of my voice as recorded on audio and/or video tape or digital media. *

Yes

I understand and agree that my image and any related recordings may be edited, copied, exhibited, published and/or distributed and I waive the right to inspect or approve the finished product wherein my image, voice and/or likeness appears. *

Yes

I understand and agree that this material may be used in diverse educational settings within an unrestricted geographic area. *

Yes

I understand and agree that Jan Luther and The Rejuvenation Station LLC and its assigns have the right and permission to use such images and/or recordings with no restrictions on the use of my likeness and voice for advertising or any other purpose in any media or format, online and/or offline, now or hereafter without further compensation, permission or notification. *

Yes

I authorize Jan Luther and The Rejuvenation Station LLC and its assigns to include my name in the use of any related images, recordings and/or transcripts. *

Yes. You can use my name.

No. Do not use my name.

I understand and agree that all images and recordings are the exclusive property, including rights of use, of Jan Luther and The Rejuvenation Station LLC and I waive any right to royalties or other compensation arising from or related to the use of my image, voice or likeness. *

Yes

Signature *

Clear

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This form collects your name, address, email address and other personal information related to Audio & Video Release Form submission to Jan Luther and The Rejuvenation Station LLC. Please click on the link at the bottom of this page if you would like to view our Privacy Policy and see how we protect and manage the information you submit.

I consent to having Jan Luther and The Rejuvenation Station LLC collect my personal information via this form. *

Yes

A copy of this form will be emailed to you for your records after you have submitted it. Thanks again!