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On behalf of myself, my heirs and personal representatives, freely grant U.S. Renal Care, Inc. (USRC), its agents, contractors, successors and assigns, irrevocable permission without remuneration to publish photographs and/or video of myself, in whole or in part, for marketing and advertising purposes which may include, but is not limited to, brochures, newsletters, billboards, signs, posters and websites. I understand that the photographs and/or video will be used in conjunction with other images, to represent USRC for potential future patients and the general public. I, the undersigned, do hereby further agree and acknowledge that I have not, and will not claim to have, either under this authorization and release or otherwise, any right, copyright, title or interest of any kind or nature whatsoever, in and to any photographs and/or video taken in which I appear, including, any such publication by USRC; and such rights are to be recognized as belonging to USRC, its successors, agents, licensees, customers and assigns. I hereby release, acquit and forever discharge USRC, its agents, officers, employees, contractors, successors and assigns from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with USRC’s possession, use or distribution of any photograph and/or video of me, including, but not limited to, claims for appropriation of likeness, invasion of privacy or false light. I will hold USRC harmless from any liability by virtue of any distortion or alteration unless it can be proven that such alteration or distortions were done with malicious intent. I have read and fully understand the contents of this authorization and release. I understand that I am under no obligation to be photographed or video recorded or sign this authorization and release as a condition of my employment, treatment or other relationship with USRC. I certify that I am at least 18 years of age and that this authorization and release is signed voluntarily, under no duress, and without expectation of compensation in any form now or in the future.*

By checking this box you have agreed to the above statement in its' entirety.

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