UC Virtual Speak Out Release Form

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Thank you for raising your voice at the UC Virtual Speak Out!

We would like to use your story in the future.

Please add your name below to grant us permission to use your photo and story.

First Name *

Last Name *

Email Address

I grant the 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 to ACLU, Equality California, NARAL Pro-Choice California, National Health Law Program, and All Care Everywhere and LightBox Collaborative as part of the Virtual Speak Out Event. I agree that the groups named above have can use these materials for purposes consistent with our shared mission to protect reproductive health, LGBTQIA2s+ rights, and evidence-based health care at public hospitals in California, including University of California Health, without religious restrictions. These uses include, but are not limited to, videos, publications, advertisements, news releases, web sites, and any promotional or educational materials in any medium. This agreement is being made in the State of California and will be interpreted in accordance with the laws of California. This agreement embodies the entire agreement of the parties (subject, photographer, and organizations). I agree with this statement. *

Yes

I understand that I will not be paid for the use of these images, video, likeness, etc. *

Yes

Required

I am over the age of eighteen (18) years and that I have read the the text above, and I fully understand what is written here on this form. *

Yes

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