CONFIDENTIALITY
By registering for this program, I hereby acknowledge that for the duration of the Twistshop program I will be sharing, and be a witness to the sharing of personal information of participants. I will respect the privacy and confidentiality of the participants within the workshop/webinar and not disclose any individual’s private information. I understand that Twist Out Cancer will not reveal personal contact information or display my artwork for reasons outside of promoting/sharing the mission of Twist Out Cancer.
CONSENT FOR USE AND DISCLOSURE OF IMAGES/VOICE/RECORDINGS
For good and valuable consideration, receipt of which is hereby acknowledged, I authorize Twist Out Cancer and its third party contractors permission to videotape or photograph me and/or my artwork (the Materials). I further give Twist Out Cancer permission to interview me and/or photograph artwork created by me in a professional setting for the purpose of future marketing or education on the therapeutic use of art therapy. I understand that my full legal name will not be revealed in any presentation or display of my artwork without my permission. I understand that for purposes of this consent, the terms “image,” “voice” and “photograph” encompass still photographs, digital images, audiotapes and any other method to reproduce or edit my likeness, image or voice, now known or hereafter developed.
Twist Out Cancer shall be the owner of the results and proceeds of such taping, photography, and recording with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use, to publish, and to license others to use in any manner, including on the Internet, all or any portion thereof or a reproduction thereof, free of any payment, royalty, or other compensation of any kind to me. I expressly understand and agree that the Materials and all results and proceeds derived therefrom, shall be the sole and absolute property of Twist Out Cancer for any and all purposes whatsoever in perpetuity, free and clear of all claims whatsoever by me and/or on my behalf. I further represent that any statements made by me during my appearance or in the Materials are true to the best of my knowledge and that neither they nor my appearance will violate or infringe upon the rights of any third party. I hereby represent and warrant that I have not given any other person, entity or firm the exclusive right to use by name, likeness, voice or photograph, and that by signing this document I am not in breach of any other agreement to which I am a party.
I hereby waive any right of inspection or approval of the Materials and my appearance in such Materials and the uses to which such Materials may be put. I agree that the Materials may be edited in the sole discretion of Twist Out Cancer and that Twist Out Cancer is under no obligation to use the Materials. I acknowledge that Twist Out Cancer will rely on this permission potentially at substantial cost to Twist Out Cancer and I hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted hereunder. I release the contracted program facilitator, and Twist Out Cancer from any and all responsibility and liability which may result from participation.
HIPAA AUTHORIZATION
I authorize my health care provider to disclose protected heath information (PHI) such as my name, address, and date of birth to Twist Out Cancer and its affiliates and their respective business partners and contractors as necessary for me to participate in art therapy programs. I also understand that third parties may be engaged to capture images and/or voice recordings associated with my participation in the art therapy programs, and that my information will be used and disclosed by these third parties in furtherance of Twist Out Cancer’s mission.
I understand that the information used or disclosed under this authorization may be shared with other people or entities and may no longer be protected by federal privacy regulations. I understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that my refusal to sign does not affect payment for services, my ability to obtain treatment, or my eligibility for benefits. I understand that if I choose to cancel (revoke) this authorization, I must do so in writing to my healthcare provider. However, I cannot cancel actions that have already been taken by relying on my authorization. Unless I revoke it earlier, this authorization will expire one year after the date of my signature or such shorter time as may be required by applicable law.
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