VIDEO/PHOTOGRAPH RELEASE FORM

With this I hereby grant “Preserva Therapy Group Inc.” DBA “Breast Cancer Victory” the irrevocable right and permission to use photographs and/or video recordings of me on “Breast Cancer Victory” and other related websites and in publications, promotional flyers, books, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet.  I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me.  I waive the right to approve the final product.  I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of “Preserva Therapy Group Inc.” DBA “Breast Cancer Victory”.

I hereby release, acquit and forever discharge “Preserva Therapy Group Inc.” DBA “Breast Cancer Victory” its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name.  This release is binding on me and my heirs, assigns and personal representatives.