General Release and Authorization for Decedent - Name, Photograph and Information

I, insert your name* , represent that I am authorized to sign this General Release & Authorization on behalf of the deceased, insert name of decedent* (“the Decedent”). I hereby authorize New York Blood Center, Inc., d/b/a New York Blood Center Enterprises (“NYBCe”*) to reproduce in any manner the Decedent’s name, photograph, story, statements, quotes, views or other background information (collectively “Name, Photograph and Information”) for publicity or public affairs purposes. I understand that background information may include health information about the Decedent. I authorize NYBCe to use that information, at NYBCe’s discretion, for the purposes stated in this General Release & Authorization.

NYBCe shall have the right to use the Name, Photograph and Information in any NYBCe publication selected by NYBCe, including publication on NYBCe’s website. I understand and accept that NYBCe will own the right to and may reproduce the Name, Photograph and Information to make them available for publication in news, promotional or other similar media (including Internet or other on-line media) with the purpose of advancing NYBCe’s mission. I also understand and accept that I shall not have the right to inspect or approve the use of the Name, Photograph and Information by or on behalf of NYBCe, nor will I receive any compensation for use of the Name, Photograph and Information.

With regard to all current and future publications in which NYBCe may use the Name, Photograph and Information, I understand and accept that my authorization will remain in effect unless and until I contact NYBCe in writing to revoke this authorization.

I also understand and accept that I may revoke this authorization at any time before NYBCe has relied upon it, but NYBCe may use and disclose the Decedent’s health information to the extent that NYBCe has relied upon my authorization. NYBCe’s reliance on my authorization begins as soon as NYBCe completes the work-product that is the subject of the publicity or public affairs activity. For example, in the case of an NYBCe newsletter, I may revoke my authorization to have the Name, Photograph and Information published in that newsletter at any time before the newsletter goes to press. Anytime thereafter, I may no longer revoke my authorization concerning that newsletter, as NYBCe will have submitted the completed newsletter to the printer in reliance on my authorization. However, I may still revoke my authorization for use of the Name, Photograph and Information in future publications for which NYBCe has not yet completed the work-product.

Because NYBCe puts a lot of time, energy and resources into conceiving and developing the work-product for its publicity and public affairs activities, NYBCe asks that you notify the following department in writing as soon as possible if you decide to revoke your authorization:

NYBCe Corporate Communications
310 E. 67th Street
New York, NY 10065
(212) 570-3220

* NYBCe is comprised of five operating divisions: New York Blood Center, Rhode Island Blood Center, Blood Bank of Delmarva, Innovative Blood Resources (Memorial Blood Centers and Nebraska Community Blood Bank), and Community Blood Center of Greater Kansas City

(Signature)*

Name*

First NameLast Name

Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Blood Drive/Event Information

If applicable, please indicate the blood drive or event information.

Blood Drive/Event Information Date (if applicable)

Date