Media Release Form – United Tissue Resources

Media Release

My name is

Name(Required)

and I agree to give a public testimonial on behalf of United Tissue Resources. I hereby give permission for United Tissue Resources (UTR) to use my name, photo(s) and/or story/excerpt (the “Testimonial”). I understand that the testimonial will be publicly displayed and may be reproduced in printed materials (such as flyers, postcards, posters, and brochures), on display signage and banners, TV and print advertisements, and on the UTR website for the purpose of publicizing, advertising, and educating people about tissue donation, and may also be used in fundraising events. I also understand that I may be sharing personal health information relating to me in connection with the Testimonial. I understand that this information may be disseminated to the public at large and, if so, such dissemination is with my authorization and approval. I expect no reimbursement for the use of photos, story and/or story excerpt and agree not to have any claim on funds that might be generated by the use of photos, story, and/or excerpt.

Signature(Required)

Date(Required)

Parent/Guardian Signature (if person is a minor, under age 17):

Daytime Phone Number(Required)

Alternate Phone Number

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Witness Signature(Required)

Witness name (print):

Date(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Media Release

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