I hereby authorize the Health and Human Rights Clinic of Indiana University McKinney School of Law, and its licensees, successors and assigns, to republish the material I am submitting to the Healthcare Access Story Project and also to interview, photograph, film, and/or audiotape me, and to use the material I submit and any photographs, video, audio and interview information (hereafter, collectively “Materials”) in any of its materials, including but not limited to publications, presentations, web sites, social media, and advertising, which the Health and Human Rights Clinic of Indiana University McKinney School of Law (hereafter, “the Clinic”) determines advances its goals.

I also authorize the Clinic to provide the Materials to other organizations, federal or state officials, media organizations and any other individual or organization which the Clinic believes is acting to advance its goals.

If the Clinic wishes that I participate in an event or a one-on-one interview, the Clinic may contact me for permission and scheduling but I am under no obligation to participate in such opportunity.   

I further understand and agree that I have no rights in the Materials, and that these Materials may be edited, used, published, distributed, republished and/or licensed by the Clinic, now or at any time in the future, for the purposes set forth in above. I waive all right to inspect or approve the use of the Materials, now or in the future.

I understand and agree that I will receive no monetary compensation for my participation or for the use of these Materials.

I release and discharge any and all actions or claims which I, my family members, or my heirs may have against the Clinic, its officers, Trustees, employees, contractors, students and/or agents, and any other third party contracting with the Clinic, arising for any reason whatsoever from any use, publication, distribution, or republication of these Materials in accordance with this Consent and Release at any time now or in the future. I agree to defend, indemnify, and hold harmless the Clinic, and its employees, directors, officers, contractors, professional advisors, assignees, students and agents, from and against any and all claims, demands, expenses, losses or liabilities including, without limitation, reasonable attorney’s fees arising out of or in connection with any breach, or alleged breach, of the terms of this Agreement.

I am above 18 years of age and understand and agree to the terms set forth above for myself or a minor on whose behalf I am submitting.