NORTH CAROLINA

RELEASE AGREEMENT

CRAVEN COUNTY

For good and valuable consideration received, which is hereby acknowledged, I

hereby give FOCUS THERAPY SERVICES, INC., (“Company”) the absolute and irrevocable consent for photographs or videotaping of my child.

Name of child: ________________________________________________________

To be taken, used, published, and copied by Company, in whole or in part, without personal identification, for illustration, trade, advertising, marketing, fundraising and promotion of Company and its activities, any medium.

I hereby release and discharge Company, its assigns and designees (including any agency, client, broadcaster, periodical or other publication) from any and all claims and demands arising out of or in connection with use of such photograph(s), or videos, including but not limited to invasion of privacy or right of publicity.

____ Accepted and agreed to:

Parent/Guardian:_________________________

Date:__________________________________

Witness:_______________________________

*If you do not want images of your child to be used by Focus Therapy Services, Inc., please sign below instead.

_____I do not want any images of my child to be used by Focus Therapy Services, Inc.

Parent/Guardian:________________________

Date: _________________________________

Documents can be returned to Focus Therapy Services, Inc., P. O. Box 12192, New Bern, North Carolina 28561