** Please Share Your Story in 500 Words or Less:
I do herby consent to the use of my story, interview, photo, video or audio recordings by University Health System, the Baptist Health System, and San Antonio AirLife for the sole purpose of promoting the services of each of these organizations.
This consent allows the use, publication, broadcast, telecast, distribution and circulation of my name photograph, image, and /or likeness for the purpose expressed above and no special favors have been promised to me for agreeing to consent. I may withdrawal this consent at any time. I understand a withdrawal of consent must be made in writing, and that withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal. I understand further, that in some cases my facial features may be visible and/ or recognizable. I (or the legal guardian, or parent signing on my behalf) am over 18 years or older, and mentally competent.
I hereby release, indemnify and hold harmless University Health System and San Antonio AirLife, its staff and employees from any and all claims or causes of action that I may have, of any nature whatsoever, which may in any manner result from the use of my story, interview, photo, video or audio recordings.
By checking this box, I HAVE FULLY READ THE FOREGOING “CONSENT FORM”. I FULLY UNDERSTAND ITS CONTENTS. I AM checking THIS AS MY FREE AND VOLUNTARY ACT.
This is a required field.