MTS Sickle Cell Foundation, Inc. Media Release / Family Consent Form and Waiver
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR VIDEOTAPE) FOR MEDIA AND PUBLIC RELATIONS PURPOSES

I hereby give consent to MTS Sickle Cell Foundation, Inc. (hereinafter “MTS”) to take and use images (photographs or videotape) or sounds recordings of me and/or the minor or person named below for whom I am giving consent, and disclose confidential information about me and/or the minor or person, to or in any public media, including radio, television, internet or print, or in a MTS publication. I understand that the intended use of such images and confidential information is for advertising, marketing, fundraising or promotional purposes of MTS.

I acknowledge that this consent and authorization for release of confidential information is being made solely for the benefit of MTS and without any expectation of compensation or other benefit to the minor or person or the family thereof. To the extent that any benefit accrues or might accrue to MTS from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits.

I hereby release and forever discharge MTS (including without limitation all corporate affiliates and officers, directors, trustees, employees, medical staff members and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the information and materials described herein, and I hereby waive all rights and interest in and to such information and materials.

I have been informed that once this information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying MTS via email at mtsscfoundation@gmail.com.

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