Tell us Your Story

*By clicking submit, you hereby agree to the terms and conditions of Concorde’s standard media authorization and release policy:
 

I hereby grant permission to the rights of my or dependent's image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:
• conference presentations
• educational presentations or courses
• informational presentations
• online educational courses
• educational videos
• marketing materials
• media and news articles, stories, and alerts

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.For any interview or statements I provide to Concorde, they will be transcribed by Concorde for me to review, sign and date as a correct expression of my sentiments and words. I hereby provideto Concorde the unrestricted use of any quote or statement, so long as not taken out of context, provided by me during any interview and/or statements documented in the written transcript of the same for Concorde's use as a testimonial. Furthermore, I am granting permission to Concorde to use my transcribed statements in print and/or digital format for marketing, advertising or training purposes. 

This release and any content produced thereby expires five (5) years from the date this release is signed. There is no geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings (including transcripts of the same) collected as part of the sessions listed on this document only.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

I forever RELEASE, discharge and agree to save harmless Concorde, its representative, assigns and all persons acting under its permission or authority, from and against any and all claims, liabilities, costs, damages and obligations arising from the use of my likeness, voice and/or name as set forth herein