I understand my testimonial as outlined above and made on behalf of Dakota Child and Family Clinic (DCFC) may be used in connection with publicizing and promoting DCFC. I authorize DCFC to use my name (if agreed upon), brief biographical information, and the Testimonial as defined on this form.  

I hereby irrevocably authorize DCFC to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing DCFC’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against DCFC for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears. I hereby hold harmless and release DCFC from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization  

I hereby grant and authorize Dakota Child and Family Clinic the right to take, edit, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, website, social networking sites, and other print or digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now and in the future pertaining to Dakota Child and Family Clinic. This authorization shall continue indefinitely unless I revoke in writing. 

I understand and agree that these materials shall become property of Dakota Child and Family Clinic. 

I hereby hold harmless, and release Dakota Child and Family Clinic from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.