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    The REAL Recovery Store Consent & Release Form
    Please fill out the following. You will receive a copy to your email address upon submission.

    I hereby authorize The REAL Recovery Show, PHLV Radio, The Meeting Space, and those acting pursuant to its authority to:
    (1) Record my image, likeness, and/or voice on a photographic, video, audio, digital, electronic, or any other medium;
    (2) Use, reproduce, modify, exhibit and/or distribute any such recording, in whole or in part, in any manner or medium now known or hereafter developed (including without limitation, print publications, DVDs, internet, CD's) for any purpose that The REAL Recovery Show, PHLV Radio, The Meeting Space, may deem appropriate, including without limitation promotional or advertising efforts; and
    (3) Use my name and biographical material in connection with any such recordings or uses. I hereby waive the right to inspect or approve any such recordings and uses . I understand that The REAL Recovery Show, PHLV Radio, The Meeting Space, will be the owner of all such recordings and uses.
    I hereby release and hold harmless The REAL Recovery Show and PHLV Radio from liability for any violation of any personal or proprietary right I may have in connection with all such recordings and uses.

    I have read and fully understand the terms of this consent and release.

    By clicking "Submit" you agree to the above.