Release for the Use and Disclosure of Images, Voice and/or Written Testimonials

Including Vail Health Foundation, Eagle Valley Behavioral Health, Colorado Mountain Medical, Howard Head Sports Medicine, and Shaw Cancer Center.

Date:

I, (enter your full name)

Name:

give Vail Health and its authorized agents permission to record my testimonial, image and/or voice and grant Vail Health all rights to use these testimonials, recordings, or photographs, including those I have provided, in any format or medium for educational, promotional, advertising, or other purposes that support the mission of the hospital.

I understand that I am a volunteer and that I will not be compensated or paid for granting Vail Health the right to use my testimonials, images and/or voice.

I waive all claims I may have against Vail Health and its authorized agents relating to this release and my testimonial, images and/or voice.

Signature:

In place of your signature, you may type your full legal name here:

Address:

Telephone:

E-mail:

If Signed by Parent/Guardian/Personal Representative:

Guardian's Full Name:

Relationship:

The below signed parent or legal guardian of (enter child/disabled adult's name)

Child Name:

hereby consents to and gives permission to the above on behalf of such minor child or disabled adult.

Guardian's Signature:

In place of your signature, you may type your full legal name here:

Non-Patient Release Form

Release for the Use and Disclosure of Images, Voice and/or Written Testimonials

If Signed by Parent/Guardian/Personal Representative: