LGMD Clinic Staff Spotlight Questionnaire

I hereby consent to be interviewed, recorded, photographed, videotaped &/or filmed by representatives
of the LGMD Awareness Foundation for purposes of publication, display or broadcast (print, web, digital
display, and all other forms of media).
I agree that such interviews, recordings, articles, quotes, photographs, films, audio, or video and/or any
reproductions of same in any form; including photos, articles, videos and/or any other materials that I
personally submit, are the property of the LGMD Awareness Foundation and I relinquish any present or
future claim for reimbursement for said photographic or film reproduction of my likeness or for said
testimonials by me.
I hereby release the LGMD Awareness Foundation, its affiliates, employees, representatives, and agents
from any and all claims, demands, costs and liability that may arise from the use of these interviews,
recordings, photographs, videotapes or films, and/or any reproductions of same in any form, as described
above.
I acknowledge that I have read this consent form in its entirety, or it has been read (or translated) to me,
and I have had the opportunity to ask questions about it and understand it.