Media Consent Form

* 1. CONSENT TO PHOTOGRAPH, AUDIO, OR VIDEOTAPE FOR NON-PROFIT USE 
By electronically signing this form I, (the applicant), hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, audio or video by the California Health Collaborative.

I also grant the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I waive any right to inspect or approve any media product before publication. I also hereby release the California Health Collaborative and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. This media release will serve as my authorization for use in this instance as well as all future events with the California Health Collaborative.

I have read this release form and understand its contents. I understand that by providing my full name electronically this accounts for my legal physical signature.