PHOTO / VIDEO AUTHORIZATION AND RELEASE: I authorize Children’s Bereavement Center, Inc. (hereinafter, “CBC”), and/or their representative(s), to take photographs, slides or videos of me, without compensation to me, for the following specific purposes:

In office seminars
On websites
In social media, including but not limited to Facebook, X (Twitter), Snapchat, TikTok, Instagram and others
In print advertisements
On television
Any publications for educational, advertising, or any other purposes
I understand that: Such photographs, slides or videos may be published by CBC in any print, visual, or electronic media including, but not limited to, medical journals and textbooks, scientific presentations and teaching courses, and Internet web sites, for the purpose of informing the general public about CBC procedures and methods.  I understand that such uses may also include marketing on behalf of CBC and its associated employees and services, for which CBC and its associated employees may receive direct or indirect remuneration. 

I understand that in some circumstances the photographs, slides, or videos may display features that identify me.
I have the right to revoke this authorization in writing at any time and, if I decide to do so, I must present my written revocation to CBC at 6619 S. Dixie Highway, #302, Miami, Florida 33143. A revocation shall not affect any release of information made prior to revocation in reliance upon this Authorization.
I may refuse to sign this authorization without such refusal affecting the treatment I receive from CBC and its associated employees and services.
The information disclosed under this Authorization, or some portion thereof, is protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).  Any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by applicable federal and/or state confidentiality rules.
A copy of this Authorization is valid as the original.  I have received a copy of this Authorization.  I may inspect or copy information to be used or disclosed under this authorization, as provided by federal and/or state law.
I release and discharge CBC and their representative(s) and associated employees from all liability, including liability for negligence, that in any way arises out of:

any and all rights that I may have or may have had in the photographs, slides or videos of me that I have authorized to be used and disclosed in this Authorization; and
any claim that I may have or may have had relating to such use and disclosure of those photographs, slides or videos of me, including any claim for payment in connection with any distribution or publication of them in any medium.
This Authorization is made as a voluntary contribution in the interest of public education and I certify that I have read this Authorization and Release carefully and fully understand its terms. If I have questions about the use or disclosure of my photographs, slides, or videos, I can contact CBC at 888-988-5438 or events@childbereavement.org.

By completing this purchase or ticket registration, I acknowledge (or a parent or adult guardian for all children under 18 years) having read and agreed to the above release and waiver including the refund policy.