Authorization for Media and Photo Release - Calendar and Annual Report

Acknowledgement*

Media/Photo Release For Faces of Transplantation Calendar and Annual Report:

I, (individual, representative or guardian) hereby authorize the release of information concerning the medical condition and other pertinent social information about the individual listed below (self, child or other party for whom I have the authority to authorize on behalf of) by LifeLink. I also authorize the shooting and releasing of photographs and/or video recordings by LifeLink employees or by any representative of the media.

This agreement is intended to release all LifeLink personnel and photographers from liability in the event that this information is released to the public for any non-commercial use.

I waive any right to inspect or approve the final copy, photographs or video that may be used or the use to which it may be applied. This authorization is ongoing, and is without limitation or restriction to time.

I HAVE FULLY READ THIS AGREEMENT BEFORE SIGNING AND I FULLY UNDERSTAND IT'S CONTENT.

Check here to indicate that you have read and agree to the Release as outlined above.

Name (Individual Filling Out Form)*

First Last

Relationship to Participant*

Self
Parent/Legal Guardian

Name of Participant (If Other Than Individual Filling Out This Form)

First Last

Today's Date*

Contact Email*

Contact Phone*

Address*

Street Address Address Line 2 City State ZIP Code

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General Authorization for Photo and Media Release

All individuals participating in a LifeLink Faces of Transplantation Calendar and Annual Report photo shoot must have this form submitted.