Apply to Be a Free Model – Consent & Release Form

DR RUSNAK ACADEMY MODEL CALL & CONSENT FORM

Thank you for your interest in becoming a model for Healing Skin Medical Aesthetics & Dr Rusnak Academy training events.

Services are provided free of charge in a training environment under the supervision of Dr. Cecilia Rusnak.

Results are not guaranteed and additional treatments may be required in the future.

By completing this form, you consent to treatment, release liability, and authorize the use of your images/videos.

First Name *

Last Name *

Phone *

Email *

Date of birth *

Instagram Handle

What type of model opportunity are you interested in? *

Service Interest

If “Other,” please specify

Do you have any allergies (e.g., pigments, lidocaine)? *

Allergies

Have you had previous tattooing, microneedling, or skin treatments in the area? *

Previous Procedures

Do you have any health conditions we should be aware of? *

Health

Upload clear photos of the area to be treated

Upload up to 3 photos

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 3 Files )Photos

Consent & Release Agreement

Please review carefully. By checking the boxes below, you agree to the following terms:

Treatment Consent (Required) *

I understand this is a free model service performed in a training setting. Results are not guaranteed, and additional treatments may be needed.

Treatment Risks (Required) *

I consent to treatment under the supervision of Dr. Cecilia Rusnak and her students. I understand potential risks, including irritation, incomplete results, or further procedures.

No Financial Liability (Required) *

I understand there is no financial compensation, refund, or guarantee associated with model services.

Photography & Media Release (Required) *

I grant Healing Skin Medical Aesthetics and Dr. Cecilia Rusnak unrestricted rights to photograph, film, and use my images/videos for training, education, and marketing purposes.1

Ownership of Content (Required) *

I acknowledge that all images and videos captured during my treatment become the property of Healing Skin Medical Aesthetics and may be used without limitation.

Marketing Consent (Optional)

I would like to receive updates about promotions, treatments, and training events.

Transactional Messages Consent *

By checking this box, I consent to receive transactional messages related to my account, services, or model participation. These messages may include appointment reminders, service updates, and account notifications. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Marketing & Promotions Consent

By checking this box, I consent to receive marketing and promotional messages from Healing Skin Medical Aesthetics, including offers, service updates, and events. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

I acknowledge that I am volunteering as a model for services provided during a training session at Healing Skin Medical Aesthetics under the supervision of Dr. Cecilia Rusnak. I understand these services are offered free of charge and are intended for educational purposes. I accept that results may vary, may be incomplete, and additional treatments may be necessary at my own expense.

I release and hold harmless Dr. Cecilia Rusnak, Healing Skin Medical Aesthetics, all instructors, students, and affiliates from any liability for outcomes, side effects, or dissatisfaction related to these procedures. I understand that no warranties, guarantees, or assurances have been made regarding results.

I grant Healing Skin Medical Aesthetics full and irrevocable rights to use, reproduce, and publish any photos, videos, or recordings taken during my participation. I waive all rights to inspect, approve, or receive compensation for such use. All images and recordings shall be the sole property of Healing Skin Medical Aesthetics.

By signing and submitting this form, I confirm that I have read, understood, and agree to the above terms, including the following communications consents:

I consent to receive transactional messages related to my account, appointments, and services I have requested. These messages may include reminders, confirmations, and updates. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.
(Optional) I consent to receive marketing and promotional messages, including special offers, new services, and updates. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.
My submission of this form and signature below indicate my full and voluntary agreement to these terms.

Signature of Participant

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Signature