I, the undersigned (“Releasor”), hereby grant to ____________________ (the “Institution”), and its affiliates, subsidiaries, parent company, successors and assigns, all rights and unrestricted permission to use and reuse my “name, image, likeness, voice, spoken words and written statements” (my “Persona”) and to use and reuse, publish and re-publish in whole or in part, individually or in conjunction with other works, my work entitled or referred to as "_______________________________________" (the "Work"), if applicable. My Persona (including any “Statement”, as defined below) and Work may be used in any form or through any media whatsoever, including, without limitation, photographs, illustrations, pictures, video recordings, audio recordings, audio-visual recordings, websites, applications, live events, or any media now known or hereafter to be developed, or with any intentional or unintentional alterations or distortions, for advertising, publicity, art, promotion or other commercial purposes. I hereby release, acquit and forever discharge the Institution, its agents, assigns, officers, directors, employees, parent company, subsidiaries, and affiliates from any and all claims or liabilities arising as a result of any use of the Work, Statement, or Persona in any medium. This release shall be binding upon my respective heirs, executors, licensees, legal representatives and assigns.  

I hereby waive any right to inspect or approve, and understand and acknowledge that I have no ownership interest in, the finished product or materials created in accordance with this release, or the advertising copy or other material that may be used in connection with such product or materials, or the uses to which it may be applied.  

I represent and warrant that any statements I have provided to the Institution (“Statement”), if applicable: i) reflect my honest, original, and truthful beliefs and opinions, ii) are based on my personal experience with the Institution, iii) have been given voluntarily, and iv) were developed prior to becoming aware that the Institution may use or compensate me for my Statement. If at any time my opinion in my Statement changes, I will notify the Institution in writing at the address listed on the Institution’s website, to the attention of the General Counsel. I also understand that the Institution may contact me from time to time to ensure I still hold the opinion contained within my Statement.  

I understand that I have no right to approve the advertising or materials created pursuant to this release and that the Institution is not obligated to use the Work, Statement, Persona, or information relating to me in any manner or respect.

I warrant that I am at least 18 years old (or that I have the consent of a parent or legal guardian as indicated below), that I have the right to execute this release in my own name, that I have read the above authorization prior to its execution, and that I am fully familiar with the contents thereof.