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Share Your Story Consent Form

Advocates 4 Breast Cancer, Inc (A4BC)

CONSENT AND RELEASE

I have read this Consent and Release form, or someone has read this Consent and Release form to me, and I understand its terms. I have been given the opportunity to ask all of the questions I have, and all of my questions have been answered to my satisfaction.

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby give my consent and grant to Advocates 4 Breast Cancer, Inc (A4BC) and its agents, the unlimited, perpetual, worldwide right to (i) produce, reproduce, print, publicize, advertise, publish, edit, display, copyright, transmit, use, and distribute, in print and/or electronically, including posting to the Internet, the words I used to express my personal story of my unique experience(s) with the United States health care system (“My Story”); and (ii) use my name, video, story, and other personal data I provide to A4BC below (“Personal Information”) in connection with My Story, and in any advertising, publicity, and/or printed matter that may be distributed or transmitted in connection with My Story. I acknowledge, however, that A4BC is not obligated to use any of my Personal Information in connection with My Story.

 

I hereby represent that the following statements are true and accurate:

  • The video and/or message submitted as My Story is of me and not any other individual
  • The video and/or message submitted as My Story was taken on the date stated by you as agreed to
  • The content of My Story is an accurate reflection of my own experience with the country of my origin's health care system.
  • I am at least 18 years of age.
  • My Personal Information is true as of the date agreed this Consent and Release.