PHOTO CONSENT  for

The Healing Exchange BRAIN TRUST

and www.braintrust.org

 

                    People are the FOCUS of our community.

We want to highlight the people building our online communities on our website.

Thank you for being an important part of “The Healing Exchange” of information and support!

 

Please mail or fax to: T.H.E. BRAIN TRUST                      

186 Hampshire Street, 2nd Floor

Cambridge, MA 02139-1320             

 

Questions? call: 877-252-8480

 

Fax: 617-876-2332


I authorize the The Healing Exchange BRAIN TRUST to use, display or publish
photographs or images in which I,

 <print name of person in images on line below>

 _________________________, appear, without limitation.

I hereby acknowledge that T.H.E. BRAIN TRUST is not responsible for any
unauthorized publication of my image or any consequences of such publication.

I understand that I may request my image to be removed from the website at any time,

although it may not be possible immediately. T.H.E. BRAIN TRUSTwill make reasonable

 effort to accommodate my request.

I understand my name will NOT appear in association with the photograph
unless I authorize it by checking one of the boxes and filling in the name I
want to use on the blank line below.

 

By submitting this form with out checking a box I agree to the default statement that:

 

I permit my image to be used with no identifying name attached. 

 

You may add personally identifying information to your image by checking a box below.

[   ]  I permit my first name ONLY to be used. My name is___________________

[   ]  I permit my full name (first and last name, middle name optional)  to be used.

            My full name is ___________________

[   ]  I wish to be identified ONLY by a "nickname" My nickname is  _____________

 

By signing and submitting this form I permit The Healing Exchange BRAIN TRUST

to use my image,

or that of the minor, or person who cannot sign,  for whom I am submitting this form.

Signature:

__________________________________________  ____  _____________     

PRINT: Name of person who will appear in image      Age     Date


__________________________________________   ____  _____________    
PRINT: Name of individual authorizing publication    Age     Date

 

__________________________________________            _____________    

SIGNATURE: of individual authorizing publication                Date

PostalAddress:________________________________________

 

____________________________________________________

____________________________________________________

EmailAddress:________________________________________