Materials Release

In consideration for my participation in First Responders Children’s Foundation PSA and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby submit to First Responders Children’s Foundation (“FRCF”) my personal artworks, paintings, graphics, drawings, sculptures, photographs, images, likeness, audio visual recordings, questionnaire responses, data, information, or any other works submitted to FRCF (“Provider Content“) for possible use in connection with the Event (defined below) and hereby irrevocably grant to FRCF and its parent entity, affiliates, and subsidiaries, and their respective licensees, employees, agents, successors, and assigns (“FRCF Parties”), the following rights under the terms set forth below:

All right, title and interest in and to the Provider Content and each element contained therein (including, without limitation, all copyrights); and

The irrevocable, exclusive, right, license, and permission to utilize, in connection with the Event (hereinafter defined), the Provider Content or any portion thereof, and to utilize my name, voice, likeness, appearance, performance, and any material(s) incorporated into the Provider Content (e.g., artwork, dialogue, musical composition(s), literary material, personal information, etc.), including, without limitation, all copyrights.

As used herein, “Event” shall refer to any and all promotions, commercials, pre-Event activities, post Event promotions for future events, sponsorships, social medial advertising campaigns, or any other promotional activity regarding First Responders Children’s Foundation PSA, any materials related thereto, and/or any materials in which the Provider Content or any portion or frame thereof might be included as an element (be it on the Internet, television, social media, print media, billboards, theatrical motion pictures, home video, any form of compilation, and/or in any and all media whether now known or hereafter devised throughout the universe in perpetuity).

The use of the Provider Content granted to the FRCF Parties hereunder may include, but is not limited to, (a) Internet, including, but not limited to posting Provider Content on all FRCF websites and in galleries and streaming Provider Content via FRCF’s digital network; (b) all social media, including, but not limited to, Facebook, Twitter, MySpace, YouTube, Instagram, Pinterest, Google +, and Foursquare; (c) on air broadcast, digital or otherwise, for any purpose; and/or (d) use in connection with the production, distribution, exhibition, advertising, merchandising, telecasting, and/or other exploitation of the Event, in any and all media, whether now known or hereafter devised, including but not limited to home videos, commercials, any new media, videocassettes, CDs, DVDs, compilations, the Internet, printed media, billboards, product merchandising, theatrical motion pictures, digital and electronic devices (including gaming devices and entertainment handheld devices and consoles such as XBox and cell phones), and all television, throughout the universe, in perpetuity.

I also agree that the FRCF Parties may use the Provider Content and any portion thereof, and my name, voice, likeness, appearance, performance, and biographical information to publicize and promote the Event and/or broadcaster’s (or other applicable broadcast entity’s or exhibitor’s) services, and that the FRCF Parties may sell, assign, or license its rights hereunder to any third party in its sole discretion and without providing any further consideration to me.

Section 3. I understand and agree that I will not receive any compensation if the Provider Content is included in the Event or is otherwise utilized by any of theFRCF Parties.  Further, I understand that the Provider Content may be edited for any reason and in any manner (including, without limitation, for reasons of content, presentation, and time) and may, to the extent decided by FRCF, in its sole discretion, have sound effects, music, host voiceovers, and/or other elements added to the presentation, and that the FRCF Parties may use, adapt, and modify the Provider Content or any portion or element thereof and to combine it with other materials in connection with the Event. I agree that the FRCF Parties will have the right from time to time and at any time to cut, edit, add to, subtract from, arrange, rearrange, shorten, and revise the Provider Content in any manner and by any method which FRCF may in its sole discretion determine, and that I expressly waive any so-called “moral rights” that may now or may hereafter be recognized including, without limitation, any right to object to any alteration of the Provider Content. I understand that nothing shall require FRCF to use the Provider Content in any manner or to broadcast or otherwise exhibit the Provider Content in any way, it being understood and agreed that all such matters are within FRCF’s sole discretion.

I hereby release, discharge, and hold harmless the FRCF Parties and their respective officers, directors, employees, agents, licensees, successors, and assignees from any and all claims whether at law or in equity (including without limitation, injunctive relief) that I may have at any time by reason of any such use, exploitation, or the exercise of any rights granted hereunder and/or arising from a breach of my agreements, representations, and warranties hereunder. I acknowledge that, in the event of a breach of this agreement by FRCF or any third party, the damage, if any, caused me thereby will not be irreparable or otherwise sufficient to entitle me to seek or obtain injunctive or other equitable relief. I acknowledge that my rights and remedies in any such event will be strictly limited to the right, if any, to recover damages in an action at law, and I will not have the right to enjoin the production, exhibition, or other exploitation of the Event or any related rights with respect thereto.

I represent and warrant as follows: (1) that I am the sole and exclusive owner of the Provider Content and have the full right and authority to enter into this agreement and to grant the rights herein; (2) that the making, exhibition, distribution and/or other exploitation of the Provider Content in connection with a Program does not violate or infringe any intellectual property rights of any third parties or constitute a defamation or invasion of privacy or right of publicity; (3) that I have obtained the written consent, release, and/or permission of each and every identifiable individual person in the Provided Content submitted to use the name or likeness of each and every such identifiable individual person to enable inclusion and use of the Provider Content in the manner contemplated by the terms of this Agreement. I hereby agree to indemnify and defend the FRCF Parties against any and all losses, claims, debts, demands, liabilities, attorneys’ fees, and all other damages or costs arising from or related to a breach of any of the above representations, warranties, and agreements or the falsity of any of these representations or warranties, including, without limitation, any and all claims by third parties that their consents and permissions were never obtained.

This release will be governed by and construed under and in accordance with the laws of the State of Texas, without regard to principles of conflicts of laws. I hereby consent and agree to the exclusive jurisdiction of the federal and state courts of the State of Texas located in Bexar County, in connection with any lawsuit, action, or proceeding arising out of or related to this agreement.

I agree to execute any additional documents which FRCF may from time to time require or deem necessary or desirable to evidence, establish, maintain, protect, enforce, or defend the FRCF Parties’ exercise and full exploitation of any of the rights I have granted herein including, without limitation, FRCF’s right, title, and interest in and to the Provider Content or any portion or element thereof. If I fail to execute and deliver such documents, I hereby appoint FRCF as my attorney-in-fact, with full right of substitution and delegation, to execute any such documents in my name and on my behalf to effectuate the purpose of this agreement, such power being irrevocable and coupled with an interest.

This agreement constitutes the entire understanding between FRCF and me, and supersedes all prior negotiations, understandings and agreements (whether written or oral) relating to the Provider Content. Any waiver of any term of this agreement in a particular instance shall not be a waiver of such term for the future. In the event that any paragraph or provision in this agreement is held invalid by a court of law for any reason, such invalidity shall have no effect upon the remaining terms and conditions of this agreement.

I certify, acknowledge and agree that: (1) I am over the age of eighteen (18) and am legally competent to sign this Agreement; (2) I have read this agreement carefully and understand its provisions; (3) I understand that I have the right to consult with an attorney; (4) I have determined that it is in my best interest to enter into this agreement; (5) I have not been influenced to sign this agreement by any statement or representation by the FRCF Parties not contained herein; and (6) I enter into this agreement knowingly and voluntarily.

HIPAA AUTHORIZATION FOR USE / DISCLOSURE OF INFORMATION AND CONSENT / USE OF PHOTOGRAPHS AND AUDIO/VIDEO IMAGES

First Responders Children’s Foundation (FRCF) is always pleased when people are willing to communicate their stories and experiences. Sharing your story can help others who are interested in knowing more about the services provided by FRCF and can help FRCF promote its mission of service.

FRCF respects everyone’s privacy. Ensuring that medical information is kept confidential is among our highest priorities. FRCF seeks your permission to use your medical information and your consent to allow us to take and use audio / video / photographic material of you in FRCF internal and external communications and distribute such materials online, in print, and in news media (such as TV, radio, newspapers, and magazines).

To ensure that FRCF is acting in accordance with your wishes, and using your personal information with your authorization, we ask you to read and agree to the terms on this form. FRCF will keep a copy of your permission on file.

  • I do give my permission for FRCF to use my or my child’s name and share details of my or his / her treatment and experience in communications produced by or on behalf of FRCF, and consent to take and make use of my and / or my child’s audio / video / photographic images in publications produced by or on behalf of FRCF. This permission extends both to electronic versions on the FRCF websites and other internet/electronic applications as well as to printed, filmed, and taped versions.
  • I do give my permission for FRCF to release my or my child’s name and details of his/her medical care to the news and electronic media including, but not limited to, internet / online publications, TV, radio, newspapers and/or magazines, and allow the news media to make images (digital, video, or otherwise) of me or my child for purposes of illustrating my treatment and experience with FRCF.
  • I specifically authorize the release of information pertaining to alcohol, drug, and/or substance abuse, diagnosis, or treatment.
  • I specifically authorize the release of information pertaining to mental health diagnosis or treatment.
  • I specifically authorize the release of information pertaining to HIV/AIDS test results.

I am not required to sign this authorization. FRCF does not condition treatment, payment, benefit eligibility, or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and audio / video / photographic material.

I am aware that my protected health information will exist forever in either a recorded, printed, and / or electronic version or other version as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that information about me or my child used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable federal and state law.

I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, I must send written notice to FRCF, 38 East 32nd Street, Suite 602, New York, NY. 10016. I understand that FRCF, as well as other persons or entities, will retain copies of any such electronic or printed versions and shall retain these versions forever and that any revocation of this authorization will only extend to the versions of the information within FRCF control that have not been previously published.