DFWCHREG

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to [Full Court Advantage/SwinCity Mag], its affiliates and agents, to use my image/video and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:
Authorizing Full Court Advantage and its affiliates and agents to take photographs or produce videotapes, audiotapes, electronic files, or other types of media productions that capture my name, voice and/or image, to be released to members of the media, or to be used by Full Court Advantage for the purpose of:
• News media (online, print and/or broadcast)
• Websites and social media
• Publications and/or promotional materials
• Medical and/or educational training
• Closed circuit television programs
• Any other lawful purpose
• Advertisements
The information to be disclosed includes:
•Photographic images of me
•Video or audio of me and/or my voice
(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
(b) Permission to use my name; and
(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.