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1. Name (Required.)

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3. Phone

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5. Which event will you be attending? (Required.)

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6. How did you hear about the Brother 2 Brother Group Discussion? (Required.)

Personal Consent & Release Form
Photography, Taping, and/or Recording

By submitting this registration, I hereby give Montgomery County, MD and its Department of Health and Human Services (DHHS), the African American Health Program (AAHP), the Executive Committee/Coalition (EC), and McFarland & Associates, Inc. the absolute and irrevocable right and permission with respect to the photographs, video, films and/or voice/audio recordings taken of me or in which I may be included with others:

A.     To copyright the same in Montgomery County’s DHHS’s, AAHP’s, EC’s, McFarland’s, or any other name these entities may choose;

B.     To use, reuse, duplicate, reproduce, publish, and republish in perpetuity the same in whole or in part, individual or in conjunction with other photographs and/or recordings, in any medium (all media) and for any purpose whatsoever, including (but not by way of limitations) illustration, promotion, advertising and trade and;

C.     To use my name in connection therewith if Montgomery County, DHHS, AAHP, EC or McFarland & Associates so chooses.

I hereby release and discharge Montgomery County, MD, DHHS, AAHP, EC, and/or McFarland& Associates, Inc. from any and all claims and demands arising out of or in connection with the use of the photographs, film or video/audio tape including, but not limited to any claims for defamation or invasion of privacy.

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