Location Release Form

Location Release Form

Our mission is to provide innovative video collections of real patients and therapists that inspire clinical excellence for faculty, students, and clinicians in occupational therapy and physical therapy programs worldwide.
Name of Institution/Facility*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address
Filming Dates
From*

MonthDayYear
To*

MonthDayYear
Filming Dates
Representative Name*

First NameLast Name
Title/Role*
Representative Email*
example@example.edu
Phone Number*

Area CodePhone Number
Check here if you prefer to keep your institution/facility anonymous.

Please review and sign the agreement below.
Location Release Form

I, {representativeName}, the authorized representative of {nameOf}, hereby grant permission to International Clinical Educators, LLC ("ICE"), its affiliates and agents, to record and photograph on the property:

{physicalAddress}

This permission is for the purpose of recording and photographing educational content. ICE may use the resulting recordings and photographs for educational, promotional, and informational purposes, including but not limited to internal and external publications, media activities, and for any other lawful purpose. The permission granted to ICE to use these materials has no time limit. This agreement is given without expectation of compensation or other remuneration, now or in the future.

By signing below, I acknowledge that:
- ICE holds patient care with the utmost priority and will seek to minimize any interruption of services.
- Recordings may include individuals who have provided their own documented consent to ICE.
- All recordings and materials produced belong solely to ICE and may not be used by the facility or any third party without express written consent from ICE.
- ICE is not liable for events that occur during regular therapy sessions conducted by the facility's employees.
Acknowledged and Agreed as of {date}.
{representativeName}

{titlerole}
Signature*

Clear
Date

MonthDayYear
Licensee:
{representativeName}
{titlerole}
Should be Empty: