Name *

First Name

Last Name

Please identify with one of the following *

I am a parent who had/has a child in the NICU

I am a NICU Medical Professional

Photo Release *

I hereby grant Project NICU (Organization) the absolute and irrevocable right and unrestricted permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the Organization or its partners. I agree that the Organization has complete ownership of such material and can use said material for any purpose consistent with the Organization’s mission. These uses include, but are not limited to, videos, publications, advertisements, news releases, Web sites, and any promotional or educational materials in any medium. I acknowledge that I will not receive any compensation for the use of such images, video, likeness, etc. I hereby release and discharge the Organization, and its agents, representatives and assignees from any and all claims and demands arising out of or in connection with the use of my name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of image, and/or defamation. I represent that I am over the age of eighteen (18) years and that I have read the foregoing and fully understand its contents.* This release shall be binding upon me, my heirs, legal representatives, and assigns.

I agree

General Release *

In consideration for being allowed to participate in Namaste for the NICU, I release from liability and waive my right to sue Project NICU (known as organization), their employees, officers, volunteers and agents from any and all claims, including claims of negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my participation in this Activity. I am voluntarily participating in this Activity. I understand that there are risks associated with my participation in this Activity, such as physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death or economic loss. These injuries or outcomes may arise from my own or other’s actions, inactions, or negligence, or the condition of the Activity location (s) or facility (ies). Nonetheless, I assume all risks of my participation in this Activity, whether known or unknown to me, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I have read this document, and I am authorizing it freely. I understand the legal consequences of signing this document, including (a) releasing the Organization from all liability, (b) waiving my right to sue the Organization, (c) and assuming all risks of participating in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I am the parent or legal guardian of the Participant. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing the Organization from all liability on my and the Participant’s behalf, (b) waiving my and the Participants’ right to sue the Organization, (c) and assuming all risks of Participant’s participation in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I allow the Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document.

I agree