500 Montgomery Street, Suite 400, Alexandria, VA 22314

CHI Right of Publicity Release

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Release

Date

1. I hereby give permission to Children’s Hospice International, Inc, which is located at 500 Montgomery Street, Suite 400 Alexandria, VA 22314 (“CHI”), and anyone else designated by CHI to use (including without limitation to reproduce, distribute, and display) and to adapt artwork, stories, photographs and other material (collectively, the “Works”) created by _________________ or containing the image, voice, likeness and/or name of _________________________. I give this permission for any purpose, in all media (including without limitation for use on CHI’s website, http://www.chionline.org/, and in print) and throughout the world forever on a nonexclusive basis. I have not granted to anyone else rights inconsistent with the rights that I grant to CHI in this Release.

2. I am giving this permission in exchange for and recognizing all of the benefits and support that CHI provides to children and their families.

3. This permission constitutes the entire understanding between CHI and myself with respect to the subjects discussed in this Release, and may not be amended except by a writing signed by both CHI and myself.

I have the authority to give this permission on behalf of ______________________, a minor child.

___________________________________

Print Name of Parent/Legal Guardian

____________________________________

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Please mail completed and signed form to:

Children’s Hospice International
500 Montgomery Street, Suite 400
Alexandria, VA 22314
PHONE: 703.684.0330
EMAIL: INFO@CHIONLINE.ORG
WEBSITE: WWW.CHIONLINE.ORG

 

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