Multimedia Consent Form

Multimedia Consent Form

Alzheimer Society of Alberta and Northwest Territories
At the Alzheimer Society of Alberta and Northwest Territories, we work to educate individuals about Alzheimer's disease and other dementias by sharing the stories of people living with dementia. This may also include sharing photos, videos, audio clips and blogs.

By giving the Alzheimer Society of Alberta and Northwest Territories permission to use your story, photo, video or sound clip which you are part of, you are helping us to build awareness that will bring us one step closer to our vision: a world without Alzheimer's disease and other dementias.

The Society will make every attempt to inform you each time your piece is being used.

We thank you for your participation.
Personal information:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For guardian / care partners please include:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please read the following carefully:
I grant to the Alzheimer Society and its representatives the right to reproduce, use, exhibit, display, broadcast and distribute and create derivative works of these images and recordings in any media known or later developed as well as my name for promoting, publicizing or explaining the Alzheimer Society and its activities and for administrative, educational or research purposes. I acknowledge that the Alzheimer Society owns all rights to the images and recordings.
I hearby release and discharge the Alzheimer Society of Canada, the Alzheimer Society of Alberta and Northwest Territories, and the local Alzheimer Societies, including their respective employees, directors, officers, agents, trustees, representatives, contractors, sub-contractors, volunteers, predecessors, successors and assigns, as well as any and all media outlets and/or services in which my information may be published or appear, directly or indirectly, from any and all liability and claims for damages of any kind, howsoever caused.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The Alzheimer Society of Alberta and Northwest Territories is committed to protecting your privacy and personal information. The information will be held in the strictest confidence and at no time will it be shared with third parties.
Should be Empty:

Multimedia Consent Form

Personal information:

For guardian / care partners please include:

Please read the following carefully: