Digital Yearbook Submission

Recovery Centers of America Management Company on behalf of itself and its affiliates (collectively, "RCA") is engaged in the development of photographic, video and audio recordings for advertising, promotional, educational and commercial purposes (Project).

1. The individual named above has agreed to appear in the Project and/or other production materials related to the Project, and in so doing, hereby agrees to the terms set forth in this Consent, Authorization and Release Agreement (Release).
2. I understand that my voice, name, likeness and images will be recorded by various mechanical and electrical means of all descriptions (such recordings, any piece thereof, the contents therein and all reproductions thereof, along with the utilization of my name or the minors name or other photographic or visual materials provided by me to RCA, shall be collectively referred to herein as the "Released Subject Matter").
3. I understand that the Released Subject Matter will include my personal health information that I choose to disclose.
4. I attest that the Released Subject Matter is, to the best of my knowledge, complete and accurate as of the date of this Consent, Authorization and Release Agreement.
5. I authorize RCA to disclose the Released Subject Matter for its advertising, promotional, educational or commercial purposes.
6. Any health information included in the Released Subject Matter will be subject to redisclosure by RCA and will no longer be protected by the Health Insurance Portability and Accountability Act of 1996 or any other state medical records privacy laws.
7. I understand that RCA may not and does not require that I sign this Consent, Authorization and Release as a condition of my receiving treatment or my employment.
8. My decision to not sign this Consent, Authorization or Release or to revoke my Consent and Authorization at any time will not result in any penalty or loss of benefits to which I am entitled including the quality of care I receive.
9. I hereby freely and without restraint, grant unto the RCA and its parents, subsidiaries, affiliated companies, officers, directors, employees, agents or assigns or anyone authorized by RCA (collectively referred to herein as the "Releasees"), the irrevocable right and permission to own, utilize, or alter the Released Subject Matter.
10. Said rights and permissions to use shall include, but be not limited to:
    • The rights to utilize the Released Subject Matter either by itself or in conjunction with any other medium, including without limitation, radio, film and video tape, still reproduction, television commercials, infomercials and infomercial videos, marketing materials, text transcription, internet and web use, social media, or any lawful or legitimate purpose;
    • The rights to utilize the Released Subject Matter for any RCA advertising, educational or commercial purposes, including, without limitation, all promotional, publicity and advertising uses and trade purposes, as well as using my name, and quotations in conjunction therewith;
    • The rights to copyright the Released Subject Matter, in RCA’s name or any other name that RCA may select.
11. As such, I hereby stipulate that the Released Subject Matter is the property of the RCA to do with as it will.
12. I waive any and all claims to compensation, monetary or otherwise, from RCA or any other party related to the Released Subject Matter including, but not limited to, the publication, distribution or other use of the Released Subject Matter for any purposes.
13. I understand that RCA has the right to alter, modify or otherwise edit the Released Subject Matter or to make the determination to forego the use of the Released Subject Matter.
14. I waive any right to inspect, modify, approve or disapprove any such modifications, presentation or other aspect of Released Subject Matter.
15. I understand that I will not benefit directly from signing this Consent, Authorization and Release and participating in the photography, video recording or audio recording.
16. RCA has explained to me and I understand the risks of sharing my story and I have voluntarily elected to sign this Consent, Authorization and Release knowing the risks.
17. I hereby release and hold harmless the Releasees from, and waive to the fullest extent that I may lawfully do so, any causes of action in law or equity I may have or may hereafter acquire against the Releasees or any of them arising out of or in connection with the utilization, reproduction or disposition by the Releasees or another of the Released Subject Matter including, but not limited to, defamation, libel, slander, invasion of privacy, breach of contract, copyright or trademark violation, right of publicity, or false light.
18. I have the right to revoke this Consent, Authorization and Release in writing to the photographing, video recording, and/or audio recording of me, and to request that RCA make reasonable efforts to destroy any images, video recordings, or audio recordings of me that it has obtained under this Consent, Authorization and Release, except to the extent that RCA has already acted in reliance on it.
19. If the Released Subject Matter has already been used by RCA, RCA is not responsible for retrieving and/or destroying the Released Subject Matter.
20. By signing this Release, I agree to any disclosure or implication that I sought or received treatment for Substance Use Disorder that results from Recovery Centers of America using my name, image, or voice.
21. This Release shall be governed by the Commonwealth of Pennsylvania law.

I hereby certify that I am the named Individual; have the authority to enter into this Consent, Authorization and Release Agreement on behalf of myself, and to share information regarding my health and health care; and, that I have read, understood, and agreed to the foregoing.