By signing below, I hereby authorize and permit Terry Real, Relationship Coach and The Relational Life Institute and its agents, employees and representatives (collectively, “RLI”) to film, record and photograph by audio and video my therapy sessions as part of Back To Us that I will be attending via Zoom during the timeframe of:
Tuesday, November 8, 2022
Tuesday, November 15, 2022
Tuesday, November 29, 2022
Tuesday, December 13, 2022
Tuesday, January 10, 2023
Tuesday, February 7, 2023
Tuesday, February 14, 2023
Tuesday, February 28, 2023
Tuesday, March 14, 2023
Tuesday, March 28, 2023
I also authorize other registrants of the Back To Us Course, including other couples and attendees, to observe these consultations on a live basis and to review the Recordings thereafter. RLI will receive remunerations from registrants of The Back To US Course. I further authorize RLI to use, disclose, display, publicly perform and modify the Recordings (which includes my name, image, likeness, appearance, and voice as they appear in the Recordings) for future trainings and marketing purposes on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter. I understand that RLI may receive remuneration as part of trainings where the Recordings will be
disclosed.
I acknowledge that any use and/or disclosure of the Recordings will be without my further consent or any royalty, payment, or other compensation to me. I understand that I have the right to revoke this authorization at any time, prior to use or disclosure by RLI for such purposes, and except otherwise where uses or disclosures have already been made in reliance on this authorization. In order to affect this revocation, I must do so in writing and send it to customerservice@relationallife.com. This authorization shall terminate ten (10) years from the completion date of The Back To Us Course unless revoked prior to such date.
I understand that uses and disclosures already made based upon my original authorization cannot be taken back.
Even if this authorization is revoked, I agree that RLI is and will be the sole and exclusive owner of all right, title, and interest in and to the Recordings, including all copyrights and other intellectual property rights therein, in perpetuity throughout the universe. I understand that my treatment is not conditioned upon my signing this authorization and that I have the right to refuse to sign this authorization without giving any reason.
By signing this form, I acknowledge that I have completely read and fully understand this document and consent to participate and be filmed. EACH person in the Couple MUST sign below to consent. Thank you.
