Donate Life Texas

 

DONATE LIFE TEXAS
AUTHORIZATION FOR RELEASE OF INFORMATION
For Media/Public Relations, Education and Marketing

 

PLEASE READ CAREFULLY BEFORE SIGNING

I, , am completing this agreement:

For Myself.

As the parent or legal guardian for the below listed minor children or dependents. I represent that I have the legal authority to make all decision(s) on behalf of the minor children or dependents listed below for the release of information, image and likeness per this authorization.

As the legal representative of the organ donor and / or deceased person(s) listed below. I represent that I have the legal authority to make all decision(s) on behalf of the listed organ donor and/or deceased person(s) for release of information, image and likeness per this authorization.

 

On behalf of myself and the above-listed individuals, I, the aforementioned, grant permission to Donate Life Texas (DLT), a nonprofit organization, and its officers, directors, employees, agents, contractors, and associated organ, eye and tissue procurement and registry organizations acting on its behalf, to use the image and likeness of any of the individuals listed above and any information (including confidential health information), in any form of media including photographs, audio/videotapes, electronic images and/or other works. Such use shall be for outlets including but not limited to television, newspapers, magazines, internet, organizational publications and websites, recruitment materials, and ads without limitation for any educational and promotional purposes related to organ donation or transplantation, without prior notification to me. I authorize DLT to use the name of any of the individuals listed above in connection with the information, images and/or recordings and to use, copy, reproduce, exhibit, or distribute in any medium those images and/or recordings. DLT is not required to use any information, image and/or recording obtained and may discontinue using such images and/or recordings at any time.

I understand that all negatives, prints, digital reproductions, and videotapes shall be the property of DLT and shall not be returned to me. On behalf of myself and the above-listed individuals, I release and waive any and all rights, title, claims, or interest I, or anyone else, may have to control or approve of the use of the information or identity of likeness of any of the above-listed individuals in the photographs, publications, or electronic matter that may be used in conjunction with the images and/or recordings. DLT shall have all ownership rights including but not limited to, the right to publish, reproduce, distribute and make other uses free of all claims and/or damages that I or any of the above-listed individuals may incur. On behalf of myself and the above-listed individuals, I release DLT, and those acting pursuant to DLT’s authority, from any and all state or federal law relating to patient privacy.

I, on behalf of myself and the above-listed individuals, and on behalf of anyone else claiming through me or any of the above-listed individuals, do hereby release and hold harmless DLT its officers, directors, employees, agents, contractors, and associated organ, eye and tissue procurement and registry organizations acting on its behalf and all persons associated with the creation of materials from any and all claims, damages, or liability arising from or related to the use of the information, images and/or recordings, including but not limited to any re-use, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in production of the finished product. On behalf of myself and the above-listed individuals, I agree to release DLT and those acting pursuant to DLT’s respective authority from liability for any violation of any personal or proprietary right I may have in connection with any use of any information and my likeness or image for any use described above.

I acknowledge that I have read, fully understand and agree to this release. I have been advised that I may seek the advice of counsel before signing this agreement. I understand that the information, images and likeness disclosed will be to the general public as opposed to any individual or private entity. I understand that once the information, images and/or likeness are disclosed, it will be in the public domain. I understand that I may rescind this Authorization at any time in writing. I further understand that rescission of this Authorization will be effective on the date DLT receives a notification in writing and will not affect any release performed prior to that date. This Authorization will be effective until rescinded. No oral representations, statements or inducements apart from this release have been made. I agree that I will receive no financial remuneration for the use of my or any of the above-listed individual’s image, likeness or information. This agreement is effective as of the date signed below.

 

First Name: Last Name:
Street Address:
City: State: Zip:
Phone (w/ area code): Email:

 

Individual's Signature Printed Name Date

 

Parent/Legal Guardian Signature (required if individual is under the age of 18) Printed Name Date