Permission to Be Featured

Your permission to be featured

A Champion would like to feature you (your name, a quote, and/or a photo) in an INtegrate wellness story. Please read the release below and sign to give your permission. If you would rather not be featured, simply don’t submit this form and let the Champion know.

I, the person named above, voluntarily give my permission for NuStart Health and my school corporation to record, use, and publish my name, likeness, photograph, image, voice, video, and any quotes or statements I provide, together with a description of my participation (my “contribution”).

My contribution may be used in the Champion newsletter and in other INtegrate, NuStart Health, and district communications (in print, electronic, web, and social media formats) for wellness, educational, and promotional purposes.

I understand that:

• My participation is voluntary, and I will not be paid or otherwise compensated for this use.
• Once material has been published or shared, it may not be possible to recall it, but I may withdraw my permission for any future use at any time by writing to NuStart Health at info@NuStartHealth.com.
• I release NuStart Health, my school corporation, and their staff and representatives from any claims arising from the authorized use of my contribution, including claims relating to privacy, publicity, or the way the material is edited or displayed.
• I am at least 18 years old. If the person featured is under 18, a parent or legal guardian must complete and sign this form on the minor’s behalf.

I have read this release and agree to it by typing my name as my signature below.