I hereby grant to The Phoenix Society, Inc. (“Phoenix Society”), its representatives, successors and assigns, the right to use my name, voice, image, likeness, testimonial or comment and any and all attributes of my personality and appearance without charge in connection with any film, audio tape, video tape, photograph, print media, book, illustration, animation, broadcast, interview or other media, now known or later developed, in any form, including all formats of computer readable media, produced by or for the Phoenix Society, any derivative works, and any advertising or promotional material created by the Phoenix Society (“materials”). I further specifically grant to the Phoenix Society the right to publish and/or release the materials to the news media, Phoenix World Burn Congress, sponsors and any other individual, organization or entity it chooses. “Materials” include but are not limited to: photographs, interviews and video taken during programs, events, and activities of the Phoenix Society, including but not limited to the Phoenix World Burn Congress event. “Materials” is further intended to include comments/testimonials offered during the Phoenix World Burn Congress program, written in Phoenix Society journals, written in evaluations, surveys, or offered at the Phoenix Society booth.
Examples of publication and use of materials may include but are not limited to:
Organization newsletters
Burn Support Magazine or similar publication
Marketing materials, flyers & brochures
Fundraising letters & donor correspondence
Annual reports
Websites and social media sites
Education and research programs and materials
Other publication, news, print media, radio, television, and all types of electronic communication media
This agreement does not include content from private support groups and private ‘open mic’ sessions as those are considered confidential.
I assign to Phoenix Society the exclusive and perpetual right, in all languages and throughout the world, to use, produce, publish, reproduce, manufacture, copy, display, perform, exhibit, transmit, broadcast, distribute, advertise, sell, lease, license, transfer, modify and create derivative works in any media or format for any lawful purpose.
I expressly waive any and all claims to copyright, patent or other ownership in Phoenix Society materials. I assign to Phoenix Society any and all clams of copyright I may have. I authorize the news media to videotape and/or conduct interviews for publication/airing to its viewers/listeners/readers. I hereby waive any privacy rights associated with such comments, testimonials, photography and video.
I also consent to the digital compositing or alteration of the portraits or pictures, including without restriction any changes or alterations as to color, size, shape, perspective, context, foreground, or background. I hereby waive any right I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith or the use to which it may be applied.
I understand that the images of me may be used by Phoenix Society to promote burn awareness. Knowing that such uses may intentionally or unintentionally give rise to the impression that I suffer from a burn injury. I nevertheless consent to this use. I understand and agree that I may be identified by name in printed, publication, digital, Internet, or broadcast information that might accompany a photograph, testimonial, interview, or image of me.
I understand that:
I may revoke this Authorization at any time
The revocation will not apply to information that has already been released in response to this Authorization
I must revoke this Authorization in writing to:
The Phoenix Society, Inc., 6026 Kalamazoo Ave SE #221, Kentwood, MI 49508
I may refuse this Authorization, by refusing to agree to this document.
This Agreement shall be construed in accordance with the laws of the state of Michigan. If any term or provision of this release shall be held illegal, unenforceable, or in conflict with any governing law, the validity of the remaining portions shall not be affected.
The undersigned hereby agrees to hold harmless The Phoenix Society, Inc., all persons acting under its authority, including its officers, agents, volunteers, and employees from all claims, causes of action and liability of any kind now known or unknown, based upon or arising out of this Materials Release form including, without limitation, claims of libel, slander, invasion of privacy, right of publicity, defamation, trademark infringement, and copyright infringement. I warrant that I am over the age of eighteen (18) years and that the authorizations and rights granted in this Agreement do not conflict with or violate the rights of any third party.
If I am a participant under 18 years of age, the signature of my parent or legal guardian shall constitute and be construed as the same release on my behalf.
I HAVE READ AND UNDERSTAND THE TERMS AND STIPULATIONS OF THIS MATERIALS RELEASE AND AGREE TO BE BOUND BY ALL OF THEM. IF I REFUSE, I SHALL INDICATE THIS BY THE ABSENCE OF CHECKING THE BOX, BELOW.