Space to Breathe Media Release 2023 | Cancer Care & Support

Dempsey Center›Registration Forms›Space to Breathe Media Release 2023

Space to Breathe 2023 Media Release

PARENTAL WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT FOR MINOR PARTICIPANT

PLEASE READ CAREFULLY, THIS IS A LEGAL DOCUMENT

By signing below, I give my permission for the Dempsey Center (DC), its employees and agents to release information about my involvement in the Dempsey Center’s Space to Breathe (S2B) 2023 program with other S2B participants, specifically photos and videos captured of me during my participation in this year’s S2B program.

By completing this form, I understand and acknowledge that this constitutes permission for the DC to release photos and/or videos of me from 2023’s S2B Program to other participating S2B families and teens. I understand I can revoke this permission at any time, except for any content that has already been shared by DC before the time of my request for revocation. I understand that, once photo and video content that includes me is released/disclosed to a third party (i.e., other S2B participants and families), the content may no longer be protected by federal privacy regulations and may be redisclosed by the person that receives the content. My revocation of permission must be given in writing to the DC Communications Department, signed and dated by me.

I may refuse to sign this authorization form. Partial or incomplete information will be labeled as such. I understand that, if I refuse to sign this authorization form, or if I revoke it, it may result in DC being unable to disclose any information.

MINOR PARTICIPANT/PARENT/GUARDIAN AUTHORIZATION AND ACCEPTANCE OF ALL TERMS

Minor Participant Full Name:(Required)

First Last

Date of Birth:(Required)

Name of Parent Guardian:(Required)

First Last

Description of Parent/Legal Guardian Relationship:(Required)

I understand that my typed name below will carry the same effect as my written signature.(Required)

Signature of Parent Guardian:(Required)

First Last

I understand that my typed name will carry the same effect as my written signature.

Date(Required)

Participant (or Parent/Legal Guardian) Home Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant (or Parent/Legal Guardian) Email Address:(Required)

Participant (or Parent/Legal Guardian) Home Phone Number:(Required)

Space to Breathe 2023 Media Release

MINOR PARTICIPANT/PARENT/GUARDIAN AUTHORIZATION AND ACCEPTANCE OF ALL TERMS

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