Permission, Release and Waiver of Liability for Name and Photograph Usage
This Permission, Release and Waiver of Liability (the “Agreement”) is made and entered into this _____ day of ______, 2018 by and between ______and Susan G Komen® Dallas County (“Komen Dallas County”).
For good and valuable consideration, the receipt and legal sufficiency of which is hereby acknowledged, ______agrees as follows:
1. ______represents and warrants that he/she, in his/her individual capacity has the full right, power and authority to enter into and perform this Agreement and to grant and vest Komen Dallas County with all of the rights set forth in this Agreement, free and clear of all claims, rights or obligations.
2. ______gives his/her permission to use the name ______and to Komen Dallas County for Komen Dallas County advertisements, mailings, electronic transmissions, including, but not limited to, e-mail and website and other specifically related usage (the “Use”). ______also gives permission to Komen Dallas County to use photos, pictures and other likeness for the same Use. The Use is deemed to be and is assigned and transferred to Komen Dallas County in perpetuity without reservation, condition or limitation including the right to produce, publish, distribute, transmit and exhibit the Use in any format and in any media.
3. I assume full responsibility for such Use by Komen Dallas County and I hereby release and hold harmless and covenant not to file suit against Komen Dallas County, its officers and directors, its Affiliates, its agents and representatives, its advertisers and public relations companies, and its employees and all other persons or entities associated with the Use (the “Releasees”) from any loss, liability or claims that may arise out of such Use.
Agreed to:
Name: ______
Printed Name: ______
Date: ______
Email Address: ______
Phone: ______
Success story: In the space below please provide the compelling story (approximately 200 words) of someone who received services as part of your Komen Dallas County funded program during the current grant cycle (April 1, 2018 – March 31, 2019).