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By submitting this form I hereby grant to the ���������� Association (AHA) and its representatives, employees, agents and assigns, the irrevocable and unrestricted right to use, re-use, display, distribute, transmit, copy, reproduce, publish, or re-publish, either in whole or in part, audio/visual recordings, photographs, portraits and videos of me, including my image, voice, and likeness (hereinafter called “Images”), through any media including, but not limited to any and all of its publications and website entries, for editorial, promotional, educational and/or informational purposes, internal use, art, entertainment, trade, advertising or any other purpose; and to copyright in its own name and/or publish, and/or market, and/or assign the same without payment or any other consideration or further authorization by me.

I also grant AHA all rights in such Images or videos, including the rights to reproduce and disseminate such Images, as well as to use such Images in whole or part as part of derivative works and/or supporting materials in conjunction with my own name. I understand that information disclosed pursuant to this authorization may be re-disclosed and used in a webcast and in other media outlets. I hereby waive the right to inspect and/or approve the finished video/audio tape or stream, print, or any other materials that may be used in connection with my Images, or the use to which they may be applied so long as such use shall be lawful.

I represent that I am over the age of eighteen (18) years and that I have read the foregoing and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns. I hereby release and discharge AHA and its representatives, employees, agents and assigns from any and all claims, actions, demands, and liability arising out of or in connection with the use of said Images, including without limitation any and all claims for invasion of privacy, right of publicity, and defamation.

By submitting this information, I represent that I have obtained a valid HIPAA Authorization covering all future disclosures AHA may make of this information if the disclosure includes any protected health information of the patient.