Recipient Response

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* 1. Is this limb for you or someone else?

Someone else

If this limb is for someone else, please fill out the following information about them. If it is for you, fill in the following information about yourself

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* 2. Name

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* 3. Age

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* 4. Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 5. Your Email or Recipient Email

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* 6. Is the Limb Loss...

Below wrist (missing hand)

Below Elbow (forearm and hand)

Above Elbow

Other (please specify)

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* 7. Do you allow the Million Waves Project to share your name on social media as one of our recipients?

Yes

No, I would prefer to be anonymous

Please Email your pictures to: millionwavesproject@gmail.com.

By submitting form, you hereby grant the Million Waves Project permission to use my likeness in a photograph, video, or other digital media in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of the Million Waves Project and will not be returned.

I hereby irrevocably authorize the Million Waves Project to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge the Million Waves Project from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.