I, ____________________________________ (print name), hereby authorize Healthcare Pathway Advocates, its employees, agents, contractors, and authorized representatives ("Organization") to use, reproduce, display, and publish my:
Photographs (including digital images and video recordings)*
Name and likeness*
Voice recordings*
Written or verbal testimonials*
Other identifying information: ______________________________________
for the sole purposes of education, marketing, and publication in print, digital, or online formats, including but not limited to: newsletters, brochures, flyers, press releases, websites, social media, and other marketing materials produced or used by Healthcare Pathway Etiquettes.
This authorization is valid from the date signed below and will remain in effect indefinitely unless revoked in writing. I understand that I may revoke this authorization at any time by submitting a written request to the Organization at the address listed below. I understand that revocation will not affect any use or disclosures already made in reliance on this authorization.
I understand that I will not receive any compensation for the use of my photograph, name, or other information as described above. I waive any right to inspect or approve the finished product or any written or electronic copy that may be used in connection with these materials.
I understand that my participation is voluntary and that my decision to sign or not sign this authorization will not affect my eligibility for services, care, or benefits provided by Healthcare Pathway Etiquettes.
I hereby release and hold harmless Healthcare Pathway Etiquettes, its employees, agents, contractors, and authorized representatives from any and all claims, demands, and causes of action that I may have by reason of this authorization.
If participant is under 18 years of age:
ORGANIZATION CONTACT INFORMATION For questions or to revoke this authorization, please contact: Healthcare Pathway Advocate Irene@ healthcarepathwayadvocates.com
To turn in the waiver in person, please download it and print it out!
*Click the button below to download*
