Media Consent Form

CONSENT TO RELEASE NAMES, PHOTOGRAPHS, AUDIOVISUAL RECORDINGS, AND WRITTEN PERSONAL TESTIMONY FOR GENERAL PUBLIC RELATIONS AND AWARENESS EFFORTS

I, the person named above, give consent to Mid-America Transplant for the use of my name, photographs, and/or audiovisual recordings, and written personal testimony(s) in regard to organ and tissue donation for the purpose of promoting donation and transplantation awareness through the web site, advertising efforts, educational brochures, displays, and general public relations practices.

In connection with the foregoing, I hereby release and agree to indemnify the licensed parties and their respective successors and assigns, from and against any and all liability arising out of the exercise of the rights granted by the above release.