Consent(Required) I agree to the terms and conditions below.
By signing and submitting this release, I voluntarily authorize the Pediatric Brain Tumor Foundation of the US, Inc. (PBTF) including its employees and agents to use video, written, photographic, or audio recordings of my and my family’s story and journey for purposes of promotional, informational and educational activities as deemed appropriate by the PBTF. I understand and give my permission that the PBTF may use and disclose my pediatric brain tumor diagnosis in sharing my and my family’s story. I understand that I may request filming or recording of me be stopped at any time, and I may revoke in writing my authorization to use or disclose the images or recordings as provided below. I waive any proprietary rights in the materials and any right I may have to inspect or approve the finished materials prior to release or publication. I also agree to release and hold harmless PBTF, its trustees, officers, employees, and agents from any liability related to the making, use, or disclosure of these photographs, videotapes, audiotapes, or any other form of multimedia.
I understand that I may refuse to sign this authorization and that it is not a condition of receiving access to the PBTF’s family support programs and resources. I understand that I may revoke this authorization, in writing, at any time; however, I further understand that I may not revoke this authorization to the extent that action has been taken in reliance upon it. Unless revoked, this authorization will expire at the end of the useful life of the information, photograph, image or recording. I understand that this authorization will allow my protected health information to be used and reused for the purposes explained above until this authorization is either revoked by me or expires. I understand that once this information is released, it may no longer be protected by state or federal confidentiality laws and may be re-disclosed.
I hereby release, discharge, and covenant not to sue the PBTF, their administrators, directors, agents, officers, volunteers and employees, and other participants, sponsors, advertisers and, if applicable, owners and lessors of premises on which the video recording(s) takes place (each considered one of the releases herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the releasees or otherwise, and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement, I, or anyone on my behalf, makes a claim against any of the releasees, I will indemnify and, save, and hold harmless each of the releasees from any litigation expenses, attorney fees, loss liability, damage, or cost which may incur as the result of such a claim.
I have read this agreement, fully understand its terms, and understand that I have given up substantial rights by signing it and have signed it freely and without any induction or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force. If an individual under 18 years of age at the time of multimedia submission or filming is featured in the video, I acknowledge that I am their parent or legal guardian, have completely reviewed this Waiver and Release, understand and consent to its terms, and authorize their participation by my signature below. I agree that electronic submission of this waiver constitutes signature, and in doing so, I acknowledge and represent that I have read and understand this release and agree to it voluntarily.