Case Study Patient Consent Form: ICPA Case Study Consent Form

Once you register to access the forum and have read these tutorials, please submit discussion in the forum about your case and paper. After you have completed the on-line Case Study Writing course, your paper is to be submitted to this forum for further review and discussion. In the forum, you have the opportunity for a personal interaction with a doctor who will offer suggestions, directions and advise in your writing.

Please note, in this forum, your paper will be considered for completion to gain credit towards Diplomate status only. It may be months after you have acquired Diplomate status that your paper will be selected for submission to a peer reviewed journal. At this point, you will be contacted by our Research Director, Dr. Joel Alcantara to fine tune and perhaps even elaborate on your case for submission.

Please keep all records of before/ after ultrasounds, x-rays, scans, photos readily accessible for publication. We highly encourage photos of set-ups, adjusting, etc of the patient for future use. When utilizing photos of patients, please have our permission to publish forms filled out and filed for retrieval. It can be accessed here: http://www.icpa4kids.com/seminars/Diplomate_Photo_Release.htm

For Candidates seeking Diplomate status, it will be necessary for you to have a poster presentation of your Research Case Study at our Graduation Ceremony weekend which is in conjunction with our Convention in Washington, DC October 21 -24, 2010.

 

 

ICPA, INC.  PHOTOGRAPHY/VIDEOGRAPHY RELEASE FORM (PERPETUAL)

 

SUBJECT: _________________________

For valuable consideration, receipt of which is hereby acknowledged, I grant to ICPA, Inc its legal representatives, licensees, parent, affiliates, assigns, transferees and employees the absolute worldwide right and permission to photograph, record, video, copyright, use, re-use, publish, and re-publish photographic/video portraits, pictures or images of me and my property or any likeness of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium, conventional or digital and in any media now or hereafter known.  The photographs/videos may be used for the purposes of promoting ICPA, Inc, including web, illustration, publicity, promotion, art, advertising, or trade, with or without my name.  This authorization is perpetual in nature and will not expire.
 
I hereby release and discharge ICPA, Inc. parties from any and all claims for damages for libel, infringement of the right of publicity, invasion of privacy, portrayal in a false light, or any other claim based on use of the above-described material(s).

Any disputes over the formation, validity, construction and performance of this Agreement are subject to U.S. law and the model agrees to submit to the personal jurisdiction of courts in the United States of America.

I hereby warrant that I am of full age and have the right to contract in my own name and I have the full capacity, power and authority to grant this release.  However, if I am a minor, my parent or guardian has reviewed the above Agreement and consents to the above on my behalf.  I (or my parent or guardian) have read and understand the above authorization, release and agreement.  This release shall be binding upon me and my heirs, legal representatives, and assigns.

Date:
Signature:
Printed Name:
Address:
Signature of Parent or Guardian:
Printed Name: