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 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.
I authorize unrestricted permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.
I hereby relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed matter that may be used in conjunction therewith or the use to which it may be applied.
I hereby release, discharge and agree to save harmless Company, his/her heirs, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.
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. I understand that this authorization will allow my protected health information to be used and reused for the purposes as deemed appropriate by the PBTF. 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.
ASSUMPTION OF THE RISK: I acknowledge that if a video or photography project occurs in-person, I agree to accept all risks associated, including but not limited to falls, contact with other participants, weather conditions including possible high heat and humidity, path conditions, traffic, and other such risks being known to me. I acknowledge the health risks associated with the Activity, including but not limited to transient dizziness, lightheaded, fainting, nausea, muscle cramping, musculoskeletal injury, joint pains, sprains and strains, heart attack, stroke, or sudden death. I agree that if I experience any of these or any other symptoms during the Activity, I will discontinue my participation immediately and seek appropriate medical attention. In the case of injury or illness, I consent to receive medical treatment if advisable. I acknowledge and understand participation includes possible exposure to and illness from infectious diseases. While rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks related to illness and infectious diseases, even if arising from the negligence or fault of the Released Parties.
CODE OF CONDUCT: I agree that while filming onsite or in my provided multimedia, I will abide by the PBTF’s Code of Conduct for community members, which I have reviewed at www.curethekids.org/code-of-conduct.html. I understand that the PBTF staff has the right to refuse my participation and limit my future participation if I am deemed to be violating these terms.
I hereby affirm that I am over the age of majority and have the right to contract in my own name. I have read the above authorization, release, and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives, and assigns 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 I am under 18 years of age at the time of multimedia submission or filming, my parent or legal guardian has completely reviewed this Waiver and Release, understands and consents to its terms, and authorizes my participation by his/her signature below.
I agree that electronic submission of this waiver constitutes a signature, and in doing so, I acknowledge and represent that I have read and understand this release and agree to it voluntarily.