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VIDEO CONSENT AND RELEASE

I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images”), and authorize The Association of Women in Rheumatology (AWIR) and/or its affiliates and companies with whom it collaborates (collectively, "AWIR") to use, release, publish, exhibit, post on the Internet, in CD-ROMs or any other medium any of my Personal Images, as described below and understand and acknowledge by signing this consent form the following:

By signing this form, I hereby give permission to AWIR to use my Personal Images in whatever medium deemed appropriate by AWIR for any of the following purposes: (i) public relations; (ii) training and education; (iii) research. AWIR will not use the Personal Images for any other purposes.

Further, by signing this form, I agree that AWIR may contact me for purposes of providing me basic training on interacting with various types of media, or to ask my permission for other uses of my Personal Images or for my participation in other types of projects. If the subject of the personal images is under the age of 18, AWIR will contact the Parent/Guardian of the individual prior to discussing with the minor.

I understand that my Personal Images may be seen and used by AWIR throughout the world and hereby give consent to such worldwide use for the purposes stated in this consent form.

I understand that my consent is voluntary, that I am not required to sign this consent and that I may in fact refuse to sign it, thereby prohibiting AWIR from obtaining or using any Personal Images of me.

I understand that certain forms of my Personal Images may include my name, personal e-mail, postal address, telephone or fax numbers, and also give consent to their use by AWIR. I understand that the inclusion of my Personal Images in whatever medium deemed appropriate by AWIR may reveal sensitive health information about me, including health conditions.

I have the right to revoke my consent at any time, which revocation must be in writing and submitted to the Association of Women in Rheumatology

I release and discharge AWIR, its officers, agents and employees, and each and all persons involved in creating my Personal Images from any liability connected with the taking, recording, filming or publication of said interviews, photographs, slides, computer images, videotapes or voice recordings.

I waive all rights I may have to claims for payment or royalties in connection with any exhibition, televising, internet posting, or other publication of my Personal Images, irrespective of whether a fee for its use is charged by any third party.

If I have any questions about my privacy rights under this form, I understand that I may contact THE ASSOCIATION OF WOMEN IN RHEUMATOLOGY via email at info@awirgroup.org

I declare that I am eighteen (18) years old or older and am legally competent to execute this Consent and Release Form or that I have acquired the written consent of my parent or legal guardian. I understand that the terms herein are contractual and not a mere recital, and that this Consent and Release Form is legally binding on me.

I have read and fully informed myself of the contents of this Consent and Release Form before signing it. I understand the use of my Personal Images and knowingly consent to such use and voluntarily sign this Consent and Release Form.