consent and release - Project Inform

1 downloads 226 Views 311KB Size Report
([email protected]), fax (415-558-0696) or via U.S. mail (273 Ninth ... may be made through any medium, and in
273 9th Street, San Francisco, CA 94103 (415) 558-8669 – www.projectinform.org

DESCRIPTION OF THE CAMPAIGN “I Deserve a Hep C Cure Because…” Project Inform and its community partners are initiating a campaign to counteract the rationing of hepatitis C treatment that is going on throughout the country. Many private and public payers (e.g., state Medicaid programs) are limiting access to hepatitis C treatment only to people with advanced liver disease and are denying people who actively use drugs access to the medications. The campaign will highlight the lives of people living with hepatitis C and the fact that everyone living with the virus deserves access to the medications that can cure them of hepatitis C. We will collect photographs people take of themselves, holding a sign that says, “I Deserve a Hep C Cure Because…” with the phrase completed. Attached is a sign that can be printed out and completed or people can make their own signs with paper and markers. For example, someone might complete the phrase with, “I Deserve a Hep C Cure Because… My friends and family need me” or “I Deserve a Hep C Cure Because… I take care of my aging mother” or “I Deserve a Hep C Cure Because… I have to be there for my kids” or “I Deserve a Hep C Cure Because… I have a lot more life to live”. The images will be posted on various social media outlets, such as Facebook, Tumblr, Twitter, and Instagram and used in advocacy efforts to ensure all people living with hepatitis C have access to the treatments that cure. To participate in the campaign, please sign the attached “Consent and Release Agreement” and send it to Emalie Huriaux via e-mail ([email protected]), fax (415-558-0696) or via U.S. mail (273 Ninth Street, San Francisco, CA 94103). If you have any questions about the campaign, contact [email protected] or (415) 580-7301. E-mail your photographs to [email protected].

273 9th Street, San Francisco, CA 94103 (415) 558-8669 – www.projectinform.org

CONSENT AND RELEASE AGREEMENT I hereby authorize Project Inform (PI), and its employees and agents, to take and use Images of me, as defined below, as part of PI’s social media campaign, “I Deserve a Hep C Cure Because…” (the “Campaign”). I hereby grant PI the irrevocable, perpetual and unrestricted right and permission to keep, use, re-use, publish, and republish photographic portraits or pictures (collectively, “Images”) of me or in which I may be included, regardless of whether such Images are partial or whole, composite or distorted, or changed or altered, for purposes of the Campaign. Such Images may be made through any medium, and in any and all media now or hereafter known, including but not limited to print media and distribution over the internet for illustration, promotion, editorial, or social marketing. I also consent to the use of any published matter in conjunction with such Images. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection with them or the use to which they may be applied. I understand that the Images of me may be used in public service advertisements to promote hepatitis C awareness and treatment access as part of the Campaign and understand that such use may give rise to the impression that I am living with hepatitis C. I hereby release, discharge, and agree to hold harmless PI, its legal representatives, and assigns, and all persons acting under PI’s permission or authority from all liability, including without limitation any claims for libel or violation of any right of publicity or privacy. I hereby warrant that I am of legal age to enter this agreement. I agree that I have read this authorization, release, and agreement, prior to its execution, and I am fully familiar with its contents. This agreement shall be binding upon me and my heirs, legal representatives, and assigns. I also grant PI the right to use my name and identity in all works in which the Images may be embodied and in connection with the advertising and promotion of such works. I hereby release PI and all others acting under the authority of PI from all claims I may at any time have against them, or any claims by my heirs, legal representatives, or assigns, in connection with or arising out of the use or exploitation of the Images. I represent that I have the right to grant PI the foregoing rights and any Images I provide will be original, will not infringe upon any copyright, and will not violate any right of privacy or any other personal or proprietary right of third parties. Signature of Subject:_____________________________________ Date:____/____/____ Print Name of Subject:______________________________________________________ Subject’s E-mail:__________________________________________________________

I deserve a Hep C cure because…

TUMBLR: http://ideserveacure.tumblr.com/ FACEBOOK: https://www.facebook.com/IDeserveACure TWITTER & INSTAGRAM: #ideserveaHepCcure