MEDIA RELEASE

KCNQ2 Cure Alliance Photo Release

I hearby grant KCNQ2 Cure Alliance permission to use my/my child's likeness in a photograph in any and all of its publications, including but not limited to, website entries, Mirror entries, and videos without payment or any other consideration.

I understand and agree that these materials will become the property of KCNQ2 Cure Alliance and will not be returned.

I hereby irrevocably authorize KCNQ2 Cure Alliance to edit, alter, copy, exhibit, publish or distribute this photo for purposes publicizing KCNQ2 Cure Alliance'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, wherin my likeness appears. Additionally, I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby hold harmless and release and forever discharge KCNQ2 Cure Alliance 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 have by reason of this authorization.

I have read this release before signing below and I fully understand the contents, meaning and impact of this release. I understand that checking the box below and typing my name is equivalent to my signature.

Parents' Names Required (required)

Child(ren)'s Name(s)

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 I agree to the terms of the photo release above. Checking this box and typing my name below is equivalent to my signature.

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