Activity Submission

MEDIA CONSENT AND RELEASE AGREEMENT

Mendez for Clinical Interventions Inc.

By completing this form, I hereby provide my voluntary and informed consent to Mendez for Clinical Interventions Inc. (“the Organization”) to:

1. Use of Name, Image, and Video

I authorize Mendez for Clinical Interventions Inc., including its employees and volunteers, to capture, use, and distribute my name, likeness, photographs, and video recordings taken by me or on my behalf. Additionally, I grant permission for the use of any media I have submitted to promote the organization’s events, programs, and services. I confirm that I am responsible for the content submitted and have obtained the necessary consent from all individuals featured in the media.

2. Scope of Use

I grant permission for my image and likeness to be:

• Published in print materials, brochures, and reports
• Shared via email communications and newsletters
• Posted on the Organization’s website and social media platforms
• Featured in video content, marketing campaigns, and public relations materials
• Used in any other medium deemed appropriate by the Organization

3. Copyright and Ownership

I waive all rights of ownership, copyright, and compensation related to the media captured or submitted. I acknowledge that Mendez for Clinical Interventions Inc. holds full editorial discretion over the use, modification, reproduction, and distribution of these materials.

4. Release of Liability

I release and hold harmless Mendez for Clinical Interventions Inc., its employees, volunteers, agents, and affiliates from any claims, liabilities, or damages related to the use of my image, including but not limited to claims of defamation, invasion of privacy, or misrepresentation.

5. Duration and Revocation

This consent remains in effect indefinitely unless revoked in writing. I understand that revoking consent does not apply to media already published or distributed before the revocation date.