COVID-19 Consent & Release

I hereby authorize Senior Services Coalition, and its licensees, successors and assigns to republish the material I am submitting in the “Share Your COVID-19 Story” form and also to interview, photograph, film, and/or audiotape me, and to use the submission and any photographs, video, audio and interview information (hereafter, collectively “Materials”) in any of its materials, including but  not limited to publications, presentations, Web sites, social media, advertising, which Senior Services Coalition determines advances its goals.

I also authorize Senior Services Coalition to provide the Materials to other organizations, federal or state officials, media organizations and any other individual or organization which Senior Services Coalition believes is acting to advance its goals.

If Senior Services Coalition wishes that I participate in an event or a one on one interview, Senior Services Coalition may contact me for permission and scheduling but I am under no obligation to participate in such opportunity.

I further understand and agree that I have no rights in the Materials, and that these Materials may be edited, used, published, distributed, republished and/or licensed by Senior Services Coalition, now or at any time in the future, for the purposes set forth in above. I waive all right to inspect or approve the use of the Materials, now or in the future.

I understand and agree that I will receive no monetary compensation for my participation or for the use of these Materials.

I release and discharge any and all actions or claims which I, my family members, or my heirs may have against the Senior Services Coalition, its officers, Trustees, employees, contractors and/or agents, and any other third party contracting with Senior Services Coalition, arising for any reason whatsoever from any use, publication, distribution, or republication of these Materials in accordance with this Consent and Release at any time now or in the future. I agree to defend, indemnify, and hold harmless Senior Services Coalition, and its employees, directors, officers, contractors, professional advisors, assignees and agents, from and against any and all claims, demands, expenses, losses or liabilities including, without limitation, reasonable attorney’s fees arising out of or in connection with any breach, or alleged breach, of the terms of this Agreement.

I am above 18 years of age and understand and agree to the terms set forth above for myself or a minor on whose behalf I am submitting.

Click here to go back to the ‘Share Your COVID-19 Story’ form.

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