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American Osteopathic Association (AOA)
Patient-Model Release Form

American Osteopathic Association
JAOA—The Journal of the American Osteopathic Association
142 E. Ontario St., Chicago, IL 60611-2864
Phone: (800) 621-1773
Fax: (312) 202-8200

I hereby give the American Osteopathic Association or its assignees permission to use the photographs taken of me in any manner it deems proper. I relinquish all rights, title, and interest that I may have in the finished photographs, negatives, and copies for this purpose, including but not limited to print and electronic media. I waive the right of prior approval and hereby release the American Osteopathic Association from all claims for damages of any kind based on this use of said material. I am of legal age and freely sign this release, which I have read and understand.

_____________________________________		__________
Patient-model's signature	Type (or print) full name	Date

For minors only:

_____________________________________ __________ Signature of patient-model's parent or legal guardian Type (or print) full name Date

_____________________________________		__________
Witness' signature	Type (or print) full name	Date

_____________________________________		__________
Photographer's signature	Type (or print) full name	Date

Note to JAOA authors: If you are not the photographer, please write your full name and paper title at the top of this sheet before submitting this form.

[Posted September 2004]