OnBaseU Movement Screening - West Texas Rehab

Name

Gender

Age

Purchaser's Information

Name

First

Last

Email

Phone

Mobile Marketing Consent

I consent to receive marketing emails from West Texas Rebab at the email address I provided.

Address

Address Line 1

City

State

Zip Code

Media Release

I hereby grant to West Texas Rehabilitation Center, their agents, successors, assignees, and affiliates, and their respective employees, officers, directors, board members, and representatives (collectively “Producers”) the right and permission to film, photograph, and record me, transcribe the recording, and to use my name, voice, image, information about me and any ideas or materials that I provide Producers (collectively, the “Materials”) in works created by Producers (the “Program”) and in connection with advertising, publicizing, broadcasting, producing, and exploiting the Program, in any and all media and mediums now known hereafter developed, in perpetuity. I understand that Producers are under no obligation to incorporate my appearance in the Program. Producer may edit and Video as it sees fit, and may resnlate the Material into languages other than English.

resnlate understand Your

Screenings

Basic 30 Minute Screen - $50.00
Pro 1 Hour Screen - $150.00

Payment Information

Complete Your Payment