Media Release Form Name* Phone*Email* I hereby authorize F.Y. Eye Care Associates to use my photo, video, and likeness for the purpose of promotion in news releases, photographs, video, audio, website, marketing and advertising for an indefinite period of time. If I am under the age of 18, my undersigned parent or legal guardian is executing this release on my behalf and agrees to be bound by its terms.Parent/Guardian Name* Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
