General Release and Authorization

General Release & Authorization

for Use of Name and Photograph
I, insert name* , hereby authorize New York Blood Center, Inc., d/b/a New York Blood Center Enterprises (“NYBCe”* ) to photograph, videotape or record me for publicity or public affairs purposes and to publish my photograph, videotape or recorded image (collectively “Photograph”), along with my name, in any NYBCe publication selected by NYBCe, including publication on NYBCe’s website. I understand and accept that my Photograph will become and remain the property of NYBCe and that NYBCe may reproduce and make it available for publication along with my name 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 have no right to inspect or approve my Photograph or use of my Photograph and name by or on behalf of NYBCe, nor will I receive any compensation for use of my Photograph and name.

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

Because NYBCe puts a lot of time, energy and resources into conceiving and developing the work-product for its publicity and public affairs activities, NYBC 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)*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Blood Drive/Event Information
If applicable, enter blood drive or event name.
Blood Drive/Event Information

MonthDayYear
If applicable, enter date of blood drive or event date.
Are you 18 years or older?*

YesNo
I, insert name* , hereby represent and warrant that I am the parent or guardian of the minor whose name and Photograph are at issue in this General Release & Authorization. I represent and warrant that I have the authority to consent and to act on behalf of the minor. I authorize NYBC to photograph the minor, and I agree that I and the minor will be bound by all of the provisions of this General Release & Authorization concerning the name and Photograph of the minor.
Signature*

Clear
Date*

MonthDayYear
Date
Name of Parent or Guardian*

First NameLast Name
Name of Minor*

First NameLast Name
Relationship to Minor*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Should be Empty:

General Release & Authorization