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B
URKE REHABILITATION CENTER
Injury and Liability Release Form
In consideration for letting __________________________________ film at Burke Rehabilitation
(
company, group or individual)
Center, I hereby release Burke Rehabilitation Center, its trustees, employees, agents and representatives from
any and all liability to ___________________________________, and agree to not raise any claims or institute
(company representative)
any legal action against Burke, its trustees, employees, agents or representatives based upon any cause of action
in my favor that arises out of or in connection with my taking photographs or filming at Burke. This release shall
apply to any loss of or damage to my property, and to any personal injury (including death) that I suffer,
including, without being limited to, any loss, damage or injury sustained or allegedly sustained by me due to the
negligent acts or omissions of the trustees, employees, agents or representatives of Burke.
I fully understand and assume all of the risks, dangers and responsibilities connected with photography
or filming at Burke Rehabilitation Center. I also agree to assume responsibility for any and all damage to Burke's
property which arises out of or in connection with my use of Burke campus for this purpose.
I agree not to film or photograph any patients or employees of Burke, unless otherwise agreed upon and
with signed releases of participation, and I agree that I will indemnify Burke for any claims against it and for any
expenses or liabilities it suffers as a result of any injury or property damages such patients or employees suffer
as a result of my use of Burke for the purpose of filming/photography.
_________________________________________________
Signature
_________________________________________________ __________________________
Name (please print) Date
_________________________________________________ __________________________
Staff Signature Date