What is the purpose of this consent form?
The CementWorks, LLC d/b/a The CementBloc (CementBloc) is soliciting actual (real-life) caregiver experiences, for the purposes of raising awareness and creating community and may include some of that information in our advertising, promotion, and education programs.
Types of information you can provide.
Do not provide your last name in the content you provide to be displayed, published, broadcast, reproduced or distributed. In addition, do not provide any identifying information with respect to or pictures or video of the person to whom you are providing caregiving services. Also, do not include any other person in any video or photograph unless that person also enters into this consent form and that person is at least 18 years of age.
What am I consenting to by agreeing to this form?
By agreeing to this consent form, I am giving CementBloc, its clients, its independent contractors, and its affiliates and successors and assigns authorized by CementBloc, the right to use, copyright, license, publish, broadcast, display, reproduce, and distribute in any manner and medium (including, without limitation, print, video, and on web sites), in color or otherwise, video and photographs of me, my name and personal information, and personal experiences in connection with my role as a caregiver. I represent and warrant that all materials and information I provide to CementBloc are true, correct, and accurate.
I hereby release CementBloc, its clients, its independent contractors, its employees, directors, officers, members, and managers, and its affiliates and successors and assigns and all persons acting under its permission or authority from any liability in connection with such use, display, broadcast, and distribution, including by virtue of any manipulation, blurring, computer imaging, or distortion, intentional or otherwise, that may be effected in the completion of the finished product, unless it can be shown by me that the publication thereof was malicious and published solely for the purpose of subjecting me to conspicuous public ridicule and scandal.
I represent and warrant that I am 18 years of age or older and have every right to contract in my own name in the above regard and have no conflicting commitments, including no advertising or promotional commitments, that would cause me to be unable to enter into and fully perform the services and grant the rights specified by this consent form, which I hereby make binding on my heirs, next of kin, and personal representatives.
What am I representing to CementBloc by agreeing to this form?
I am representing that any materials, statements, and information that I have provided to CementBloc are accurate and reflect my true and honest opinion of my experiences. Further, if I provide photographs and/or video of myself to CementBloc, I am representing that I own the copyright in those photographs and/or video or otherwise have the ability to permit CementBloc to use them as described in this form.
What can CementBloc do with my photos and/or video or personal information if I agree to this consent form?
CementBloc may have my photographs and/or video footage along with some of my personal experiences as a caregiver published, circulated or presented in any way in any media now or hereafter existing (e.g., printed advertisements, television and radio ads, web sites, and training programs). This includes the right for CementBloc to copy, reproduce, modify, adapt, and display my photographs, videos, and other images and the right for CementBloc to use, reproduce, and display my name, likeness, personal information, quotations, and other materials that I choose to provide to or share with CementBloc. By agreeing to this form, I am waiving any rights of privacy or publicity and any copyrights, moral rights or other rights in these materials and in my name, likeness, and image. CementBloc can use my information by itself or combine it with other written, printed, graphic, or audio matter. CementBloc may also edit, reduce, enlarge, or otherwise change those photographs and/or video to conform to the piece.
Will CementBloc share my information with any other parties?
CementBloc may share my photos, videos, and information on websites, in a documentary, and for purposes relating to advertising, promotion, or educational programs that relate to CementBloc's campaign or any of its clients' campaigns to raise awareness of the caregiver experience.
Am I entitled to any payments or ongoing compensation from the use of my photos or information?
You acknowledge and agree that you are not entitled to and will not receive any compensation, payments or royalties with respect to any and all such uses of your photos, videos, and information by CementBloc, its clients, its independent contractors, and its affiliates and successors and assigns.
What am I releasing by agreeing to this form?
By clicking acceptance, I understand that I am releasing CementBloc from any legal claims arising out of the use of my photographs, video, name, likeness, testimonial, and information by CementBloc, its clients, its independent contractors, its affiliates and successors and assigns, clients, and independent contractors, consistent with the allowable uses provided in this consent form.
