By checking this box, I hereby authorize Decatur County Hospital permission to use my testimonial and/or image for any purpose, including but not limited to all DCH building interiors, printed and digital publications, television, the Internet, and press releases. I understand and agree that my written experience and image will become property of DCH and will not be returned.
I hereby irrevocably authorize DCH to edit, alter, copy, exhibit, publish or distribute this image for purposes of publicizing DCH’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy.
Additionally, I waive any right to royalties or other compensation arising or related to the use of the image. DCH will credit, with your name, the image provided by you should it be selected for display in the DCH facility.
I hereby hold harmless and release and forever discharge DCH, and its agents or third parties, and all persons acting under DCH’s permission or authority 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 certify that I have read this release before submitting below and I fully understand the contents, meaning, and impact of this release. I am eighteen (18) years of age or older and if acting on behalf of a minor, have every right to contract for the minor in the above regard.
