This educational lecture will be videotaped for inclusion on the CSF website, for those who are unable to attend in person. Please read the following waiver and check the box above to indicate that you have read and understand it.
I hereby irrevocably agree and consent that you, Chiari & Syringomyelia Foundation, Inc., and your assigns may use all or part of your videotaped or filmed footage of me for your documentary/educational programs about Chiari, syringomyelia and related disorders.
You have the right to use my picture, silhouette and other reproductions of my likeness and voice in connection with any motion picture, television program, fundraising video, web or print material in which this interview may be incorporated, and/or in any advertising material promoting it. You may edit my appearance as you see fit.
You shall have all right, title and interest in any and all results and proceeds from said use or appearance.
The rights granted you are perpetual and include the use of this educational event/interview in any medium all or part of the program may be shown, including broadcast and cable television, videocassettes, DVDs, internet, or any future technologies developed for distribution and/or exhibition.
You are not obliged to make any use of this footage or exercise any of the rights granted to you by this release.