I, the undersigned, give MEN2B Foundation permission to photograph, video record, audio record, interview, quote, and/or otherwise capture my image, likeness, voice, name, story, comments, and/or written or spoken statements.
I understand and agree that MEN2B Foundation may use, reproduce, publish, edit, distribute, display, and share these materials in connection with its nonprofit mission, education, awareness, fundraising, advocacy, community-building, marketing, and promotional activities.
This permission includes, but is not limited
to, use in:
MEN2B Foundation website content, social media posts, and campaigns.
Email newsletters, press releases, media communications, and other printed materials.
Presentations, videos, brochures, and other promotional materials
Health Information Acknowledgement and Authorization
I understand that MEN2B Foundation supports individuals and families affected by MEN2B and related health experiences. I acknowledge that photos, videos, interviews, written comments, or personal stories may include or imply sensitive personal, medical, genetic, family, or health-related information.
By signing this form, I authorize MEN2B Foundation to use and disclose any health-related information that I voluntarily provide or that may reasonably be inferred from the approved materials, including references to MEN2B, diagnosis, treatment, symptoms, family medical experiences, caregiving experiences, or personal health journey.
I understand that once this information is published or shared publicly, MEN2B Foundation may not be able to control how others view, copy, save, repost, or further share the information.
Voluntary Participation
I understand that signing this form is voluntary. I understand that I am not required to share personal, family, medical, or health-related information. I also understand that refusing to sign this form will not affect my ability to participate in MEN2B Foundation events, programs, or activities, unless participation specifically requires media consent for a clearly identified purpose.
Ownership, Compensation, and Editing
I understand and agree that MEN2B Foundation may edit, crop, adapt, caption, combine, or otherwise prepare the materials for use, provided the use is consistent with the foundation’s mission and does not intentionally misrepresent me.
I waive any right to inspect or approve the final materials before use. I understand that I will not receive payment, royalties, or other compensation for the use of these materials.
Release of Claims
To the fullest extent permitted by law, I release and hold harmless MEN2B Foundation, its board members, officers, volunteers, representatives, agents, contractors, and partners from claims arising from the authorized use of my name, image, likeness, voice, comments, story, or voluntarily shared health-related information, including claims related to privacy, publicity, defamation, emotional distress, or compensation.
Duration and Withdrawal
This authorization remains in effect unless I revoke it in writing. I understand that revocation will not affect materials already published, printed, distributed, posted, or used before MEN2B Foundation receives and processes the written revocation.
Optional Limits or Restrictions
Please list any restrictions, names that should not be used, individuals who should not be photographed or quoted, or health-related details that should not be included:
Minors and Family Members
For any person under age 18 listed below, I confirm that I am the parent or legal guardian authorized to provide consent on their behalf.
This release applies to the following individuals:
Name of Individual / Family Member with Relationship
Please select either Adult or Minor
