RELEASE AND AUTHORIZATION FORM PUBLICATION/WEB SITE/PHOTO/VIDEO/INTERVIEW Question Title * 1. Name (Guardian if under 18) Question Title * 2. Date Question Title * 3. I grant Hudson Headwaters Health Network to include and identify me in any publication, photograph and audio or visual recordings of any kind and in whatever medium it may use for educational, publicity, and/or fundraising purposes. If I was interviewed by staff from Hudson Headwaters or any affiliate programs, I also give permission to use my name, my story, and any of my direct quotes for education, publicity and/or fundraising purposes in any medium. I understand and agree that Hudson Headwaters retains all rights to the photographs, moving images, sound recordings, and other media, and that I will not be compensated for any Hudson Headwaters use of same. I Agree Question Title * 4. I hereby waive any right I may have to inspect or approve media that contains my name, image, sound recordings, story, and/or biographical data. I agree Question Title * 5. I understand and acknowledge that Hudson Headwaters and its affiliate programs will rely on this Release and Authorization, and I hereby agree not to assert any claim of any nature against Hudson Headwaters, its employees and agents, and/or affiliate programs relating to the exercise of the permissions granted by this Release and Authorization. I understand and agree the materials developed during this period may be utilized indefinitely. I am signing this Release and Authorization voluntarily, and understand that provision of services to me by Hudson Headwaters and/or its affiliate programs is not conditioned on whether or not I sign it. I also understand that I may revoke this Release and Authorization at any time, in writing, but that a revocation will not impact any use or disclosure made prior to the date the revocation is received. I agree Question Title * 6. Type in Name Below : Done
