Bridging the Gaps is a program of several Universities/Academic Institutions/ Academic Health Centers* (hereinafter both collectively referred to as "Bridging the Gaps").
I, hereby agree to allow Bridging the Gaps and any of its authorized agents or contractors to record, video and/or photograph my likeness and voice. I understand that any such recording, videotape and/or photograph belongs to Bridging the Gaps and that I will not receive any payment or other compensation in connection with such recording, video or photograph. I also consent to being interviewed and I authorize the use of any information disclosed during such interview. I also give Bridging the Gaps permission to quote from any of my narrative, correspondence and/or posters panels that I create during the program and to use such quotes in any Bridging the Gaps publication, video or other materials.
I hereby give Bridging the Gaps, its employees, agents, successors, assigns, and those acting with its permission or on its behalf, the right and permission to use, copyright, publish, republish and distribute any such recording, video or photograph of me and to use, copyright, publish, republish and distribute the narrative and posters I create during the program. I understand that said recording, video, photograph, interview, narrative, correspondence and/or posters panel may be used in any media, including reproductions on the World Wide Web, in conjunction with any printed or electronic matter, and in connection with any efforts publicizing, promoting or otherwise directly related to the objectives of Bridging the Gaps. I understand that my name, affiliation (school/agency/site) date of correspondence, if applicable, may appear with any quotes or other material used.
I agree that personal satisfaction is sufficient consideration for this authorization and release and I waive all payments, royalties or other compensation. Intending to be legally bound, for myself, and my respective heirs and assigns, I hereby release Bridging the Gaps and the Universities/Academic Institutions/Academic Health Centers and their respective trustees, officers, employees, students, agents and assigns from any and all liability, and waive any and all claims or demands that I may have against any of them for damages or remuneration, in connection with the use of my likeness and voice and the narratives, correspondence, and/or posters I created during the program in the manner and for the purposes described in this authorization and release.
*Participating Universities/Academic Institutions/Academic Health Centers: Bryn Mawr College, Cooper Medical School of Rowan University, DeSales University, Drexel University, Lake Erie College of Osteopathic Medicine, Lehigh Valley Health Network, Marywood University, Moravian University, Temple University, Thomas Jefferson University, University of Pennsylvania, University of Pittsburgh, Uniformed Services University of the Health Sciences.
* must provide value