Understand That This Information Will

ARTritis CONSENT and RELEASE I, _________________________(print name), have read, understood and agree to comply with and be bound by the ARTritis Submission Guidelines and, for valuable consideration, the receipt of which is acknowledged, I consent and agree as follows:

1. I consent to the use and disclosure by The Arthritis Society, BC & Yukon Division (the “Arthritis Society”) of my photograph and/or my personal information for purposes of publicizing and promoting the ARTritis project (“ARTritis”) and my participation in the ARTritis. I understand that this information will be used only for the purposes described in this clause, and that any other use will be subject to my further consent.

2. I assign and transfer to the Arthritis Society all of my right, title and interest which I may have in the work submitted for the ARTritis and any reproductions thereof, and hereby represent to Arthritis Society that I have the right to enter into this Agreement and that the work submitted is an original. This assignment shall operate to provide Arthritis Society, all rights to have and hold the work for the full duration of all such rights.

_____________________ (Signature)

_____________________ (Print name)

_________________________ (Address)

_____________________ (Date)

Parent/Guardian to sign below if person named above is under 19 years of age

__________________________ (Signature of Parent/Guardian)

____________________________ (Parent/Guardian Address)

__________________________ (Print name of Parent/Guardian)

_________________ (Date)