Model Release

In exchange for consideration received, I hereby give permission to Hart Eye Center to use my name and photographic likeness in all forms and media for advertising, trade, and any other lawful purposes.

Print Name:                                    

Signature:                                    

Date:                                    

If Model is under 18:
I,                                     , am the parent/legal guardian of the individual named above, I have read this release and approve of its terms.

Print Name:                                    

Signature:                                    

Date: