I do give my consent to the Commonwealth Healthcare Corporation (CHCC)to use me/my child(ren)/family’s image(s) and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the internet). This content includes, but is not limited to:

• Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me/my child(ren)/family’s image(s) and/or record me/my child(ren)/family’s voice;
• Permission to use me/my child(ren)/family’s name;
• Permission to use quotes from the interview(s), the film, photograph(s), tape(s), or reproduction(s) of me/my child(ren)/family’s recording of voice, in part or in whole, in its publications in newspapers, magazines, and other print media, on television, radio, and electronic media (including internet), in theatrical media and/or in mailings for educational and awareness.
• Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me/my child(ren)/family’s image(s) and/or record me/my child(ren)/family’s voice;
• Permission to use me/my child(ren)/family’s name;
• Permission to use quotes from the interview(s), the film, photograph(s), tape(s), or reproduction(s) of me/my child(ren)/family’s recording of voice, in part or in whole, in its publications in newspapers, magazines, and other print media, on television, radio, and electronic media (including internet), in theatrical media and/or in mailings for educational and awareness.