Survey - Connecticut: Share Your Story - Alzheimer's Association

Connecticut: Share Your Story

Your story is important. We know the challenges you face. Please tell us your personal story about how Alzheimer's disease has affected your life.

Storytime

Please share the following information. NOTE:Your mailing and email address will not be shared publicly.

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CONSENT AND RELEASE

By clicking "Share" I hereby irrevocably grant in perpetuity to the Alzheimer's Association, its legal representatives or assigns, affiliates (including, but not limited to, its separately incorporated divisions or chapters and those acting under its permission and upon its authority, or those for whom the Alzheimer's Association is acting, the absolute right and permission to:
(a) copyright, use, re-use, publish, and republish, and to license the right to use, re-use, publish and republish, photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, in any medium or form of distribution without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for any purposes whatsoever, including, without limitation, illustration, art, promotion, advertising or trade (b) copyright, use, re-use, publish and republish, and to license the right to use, re-use, publish and republish my likeness and/or voice on film or videotape, to edit or change or alter such recording(s) at its sole discretion in which I may be included in whole or in part, or composite or distorted in character or form, in any medium or form of distribution without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for any purposes whatsoever, including, without limitation, illustration, art, promotion, advertising or trade; and/or(c) copyright, use, re-use, publish and republish, and to license the right to use, re-use, publish and republish my testimonial (written) and edit such testimonial in its sole discretion, in any medium or form of distribution without restriction as to changes or transformation in conjunction with my own or a fictitious name, made through any and all media now or hereafter known for any purposes whatsoever, including, without limitation, illustration, art, promotion, advertising or trade. It is my understanding that I will receive no compensation for my likeness or testimonial. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy or printed matter that may be used in connection with my likeness or testimonial or the use to which it may be applied.  I agree that I have no rights to the photographs, reproductions, negatives, videos or films, and all rights to such materials belong to the Alzheimer's Association. I hereby release, discharge and agree to save harmless the Alzheimer's Association and its employees or agents, affiliates, legal representatives or assigns and all persons acting under its permission or upon its authority or for whom it is acting, from any liability by virtue of any publication of my likeness or testimonial, including, without limitation, claims for libel or invasion of privacy, as well as any liability arising by virtue of any blurring distortion, alteration, optical illusion of use in composite form, whether intentional or otherwise, that may occur or be produced in the making of such picture or recording(s) or in any processing tending towards the completion of the finished product. I hereby warrant that I am of full age and have every right to contract in my own name in the above regard.  I state FURTHER that I have read the above AUTHORIZATION and release prior to its execution, and that I am fully familiar with the contents thereof.  This agreement shall be binding upon me and my heirs, legal representatives and assigns.[FOR MINORS ONLY]  If you are under 18 years of age, your parent or legal guardian must sign this Consent and Release Form and provide the information requested below.
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Alzheimer's Association National Office, 225 N. Michigan Ave., Fl. 17, Chicago, IL 60601
Alzheimer's Association is a not-for-profit 501(c)(3) organization.

Our vision is a world without Alzheimer's
Formed in 1980, the Alzheimer's Association is the world's leading voluntary health organization in Alzheimer's care, support and research.