Student Information

Parent/Guardian Information

Involvement in Blood Donation

0/1000 words
What were the dates and locations of the blood drive(s) you helped promote? *
Drive 1
Drive 2
0/100 words

Photography Consent and Release

I grant permission to LifeSouth Community Blood Centers, Inc. and The LifeSouth Community Foundation. hereinafter collectively and individually referred to as “LifeSouth” and its agents or employees to use photographs, video and/or audio taken of me (the “Interview”). These images and audio may be used in educational, promotional and documentary materials such as commercials, public service announcements, video documentaries and in print, audio and online form (the “Work”). Furthermore, I authorize the use of my name, image, likeness, and voice for all program promotion, materials, and any other purposes in connection with the Interview deemed appropriate and necessary by LifeSouth. I waive the right to inspect or approve use of my Interview as incorporated in the Work.
I hereby agree to release, defend, and hold harmless LifeSouth and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, sound recording, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video/audio, including but not limited to any claims of defamation, invasion of privacy or infringement of moral rights, rights of publicity or copyright, violation of HIPAA, any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution. The filmmaker/photographer agrees to retain the integrity of the interviewee's image and voice, neither misrepresenting the interviewee's words nor taking them out of context. I understand that LifeSouth will own all rights to the photographs, moving images, sound recordings, and other media, and that I will not be compensated for any use.
I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. This agreement shall be binding upon all of interviewee’s respective heirs, legal representatives and assigns.
In the event the subject of the Interview is not 18 years of age, the individual signing below warrants they are a legally competent adult and a parent or legally appointed guardian of the minor. Further, the parent or legal guardian attests they have read the above authorization, release and agreement prior to its execution, and that they are fully familiar with the contents of it. This agreement shall be binding upon the minor and the parent or legal guardian, and all respective heirs, legal representatives and assigns.
I am aware that my participation is voluntary. If, for any reason, at any time, I wish to stop the Interview, I may do so without having to give an explanation. I attest that I have voluntarily agreed to the Interview and that this document contains the entire and complete agreement concerning the use and preservation of my Interview
I have read and agree with the statements above *
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