3rd Annual ATTR-CM 1.5 mile or 5K Walk/Run

PHOTOGRAPH AND PUBLICITY CONSENT AND RELEASE I ___________________________________, (name), hereby give my consent for the U.S. Department of Health and Human Services, U.S. Public Health Service Commissioned Corps (“the Corps”) and the Black Nurses of Southern Maryland (BNSMD) to use, reproduce, exhibit, publish, broadcast, or distribute electronic materials in which I and/or my minor child(ren) (“the Subject(s)”) are pictured, including but not limited to photographs, films, and video/audio tapes (collectively, “the Materials”). ******************************************* I agree that the Commissioned Corps may use the Materials for any purpose consistent with the Corps’ mission, including but not limited to educational, promotional, or marketing purposes in support of the Corps. ******************************************* I also agree that the BNSMD may use the Materials for any purpose consistent with the BNSND mission, including but not limited to educational, promotional, or marketing purposes in support of the National Black Nurses of America Association. ******************************************* I further acknowledge that I will not receive any compensation for the use, etc. of the Materials and hereby release the Corps and BNSMD and its agents and assigns from any and all claims which may arise out of or are in any way connected with such use, etc. ******************************************* I have read this entire document, understand the contents, and willingly give my consent to the Commissioned Corps and at Black Nurses of Southern Maryland to use the Materials pursuant to the above conditions. SecureFee™ Registration Cancellation Insurance is offered in most states. If purchased, your registration may be covered for one of the covered reasons stated in the policy.