Submission Consent Form

Name(s) of Participants in Video(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Name of Song(Required)

I grant permission to Health Care Access the irrevocable and unrestricted right to reproduce the video images of me or members of my family for the purpose of publication, promotion, advertising in any manner. I hereby release Health Care Access for all claims and liability relating to said videos. I waive my right to any compensation. I have read and understand the above.

Signature(Required)