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The undersigned hereby transfers and grants to Riley Children’s Foundation (“Riley”) the exclusive right to use and to authorize others, including but not limited to Indiana University Health, Riley Hospital for Children at IU Health, and IU and its School of Medicine to use all or any part of my (his/her) interview/photograph/video or film likeness, regardless of the medium by which it is recorded.

The undersigned also hereby transfers and grants to Riley Children’s Foundation the exclusive right to use and authorize others to use all or any part of my (his/her) interview/photograph/video in related media such as books, magazines, journals, pamphlets, electronic (Internet) and other written and video formats. The undersigned also hereby releases Riley Children’s Foundation and its Board of Governors, officers and employees as well as IU Health and its agents, from any and all claims, demands, causes of action and suits, including but not limited to claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of this interview, photograph or video.

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