WI Rare Photo Release

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Photo and Video Release

I authorize Wisconsin Rare Disease Alliance to use my image, video or audio to further the mission of raising awareness and improving access to care for individuals and families with rare diseases in Wisconsin.

*The term “image” as used in this release shall mean photo, video, audio in any format and any other electronic means of recording and reproducing images.

I provide permission for my image to be used for educational and charitable purposes including public educational presentations and public campaigns in print and online including but not limited to websites, social media, and email. My image may be copied, published, edited or distributed. I understand that I waive the right to inspect or approve the finished product wherein my likeness appears and will receive no compensation for the use of my image or recording. There is no time limit on this release nor any geographic limitation on where these materials may be distributed.

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Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

By signing this release, I acknowledge that I have completely read and fully understand the above WI Rare publicity release and agree to be bound thereby.

Signature

Clear Signature

Date

Names of other family members (under 18) that you are authorizing for photo release

Legal Guardian Signature

Clear Signature

*If this release pertains to a minor, under the age of 18, the signature of that individual’s parent or legal guardian is also required