Share Your Pictures & Stories

Authorization To Use and Disclose Images and Related Information

By signing this form, I hereby authorize the Global Tracheostomy Collaborate (GTC) to use, modify and disclose Images and/or my personal story for the purposes described in this form. The term “Images” includes photographs, movies, videotapes, audio tapes, as well as any copies, prints, negatives, computer graphics or electronic images from any of the above. As applicable, I also authorize the GTC to interview me and to obtain, use and disclose information obtained for the purposes described in this form.

The permitted uses and disclosures of my Images and related information (as applicable) include:

• Articles in GTC publications (online and/or print)

• Fundraising, publicity, promotions, marketing or advertising activities of GTC

• Posting on GTC Web sites (internal Intranet and/or external Internet) or any GTC sponsored use of social media

• Articles released to the print and broadcast media (e.g. radio, television, newspapers, magazines), external websites and all types of electronic communication media and social media

• Other:

I further consent to my Images and/or story being placed in a central repository of similar materials within GTC for future use, unless I indicate otherwise. I understand that I may be identified in any use or disclosure of my Images and/or story. I hereby waive the right to receive a copy, inspect or approve the Images or related information for the purposes described above, and also waive any and all rights that I may have to any claims for payment or royalties in connection with the above use of Images or related information. I understand that GTC and its corporate affiliates cannot control how third parties may use my Images and/or related information. I release GTC, its affiliated entities, their directors, officers, employees and agents from any and all claims, actions, damages, and liability of any kind arising from any of the permitted uses and disclosures described in this form. I acknowledge that the Images and/or story are and will remain the sole property of GTC.

I understand I have the right to refuse to sign this Authorization and that this Authorization is valid unless I cancel or revoke it in writing. If I choose to revoke this Authorization at any time in the future, I will send my revocation to GTC at 2306 Anderson Drive, Raleigh, NC, 27608, USA. My written revocation will not affect any disclosure of Images or Information made before the receipt of my revocation by GTC.

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*Electronic Signature - Name of Subject(s) (or parent if < 18 years)

*Date (MM/DD/YY)

*Contact Address

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*Contact Telephone

Photographer

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