Thank you for volunteering!

We would like to be able to gather your story about what led you to volunteering and the impact you
feel volunteering has made. Our goal is to highlight the benefits of volunteering and encourage more
people to volunteer.


By completing this form, I hereby grant Beach Cities Health District, its successors, assignees and licensees
(collectively, the “District”), a non-exclusive right to record, display, publish, perform, transmit, commercialize,
distribute, copy and otherwise use (collectively, “Use”) my name, voice, signature, photograph,
likeness and image. I further grant the District a non-exclusive right to Use any copyright I may have in
my performance, speech, interview, testimonial, demonstration or materials. The rights that I am granting
to the District shall be paid up, royalty free, perpetual, worldwide and freely transferrable and sublicensable.
The District may exercise such rights through any means currently known or developed in the
future.

I agree and acknowledge that I have received sufficient consideration for the rights granted above.
I warrant and represent that (i) I am 18 years old or older and have the right to contract in my own
name; (ii) I have the right to grant the rights described in this agreement; and (iii) granting these rights
does not breach any agreement I may have with any third party or otherwise interfere with any rights
of any third party.

This release shall be binding upon me and my heirs and legal representatives. This agreement sets
forth the complete agreement with respect to the subject matter and supersedes any prior agreement
or representation. This agreement may be modified only by a written agreement signed by both
me and the District.

Question Title

* 1. Please enter your name and contact information.

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