Alzheimer’s Association Illinois Chapter

Consent and Release Form

I hereby grant the Alzheimer’s Disease and Related Disorders Association (“Alzheimer’s Association”) permission to take my photograph, record my voice, and shoot film/video footage of me (the “Images and Images and Recordings”). I hereby grant to Alzheimer’s Association the irrevocable right to use the Images and Recordings in Alzheimer’s Association educational, informational and promotional efforts, including distribution to the news media. I understand that my signature on this form signifies my consent to grant these rights. I also hereby grant the Alzheimer’s Association and those acting within its authority the unqualified right to reproduce, copyright, publish, circulate or otherwise use the Images and Recordings.

This consent and release covers the use of the Images and Images and Recordings in any form (whether now known or later invented), including print, broadcast and online use, and any media of advertising, publicity or trade in any part of the world for an unlimited period of time. I shall have no claim with respect to the use of the Images and Recordings (including, without limitation, claims for compensation of any kind or royalties or any claim of defamation or violation of rights of privacy or publicity). I hold the Alzheimer’s Association free and harmless from any and all claims and liability arising out of or in connection with the use of the Images and Recordings.

I also agree that I may be identified by name, and I fully understand that this is a complete release of all claims against the Alzheimer’s Association, or any other person, firm or corporation by reason of any such use of the Images and Recordings.

I certify that I am 18 years of age or over and represent that I am able to grant the foregoing rights.