RSRT Consent & Release Form

Individual Giving Consent

I hereby consent to the publication, exhibition, reproduction or other release, public or private, by the Rett Syndrome Research Trust (RSRT) or any representatives (including the release of any assignee, transferee, affiliated entity or license) of my or my child’s name and story, photograph, recording or other likeness (collectively, “Media”), as follows:

Name of individual giving consent

Date of birth of individual giving consent

Primary phone number

Address

Name of additional subject (if under 18)

First name

Last name

Date of birth

Media Use

Media use

Consent

I consent and release for use of Name(s) and Media in connection with future RSRT activities, events, and outreach materials.

YesNo

Electronic Signature

I hereby waive all claims for damage or loss incurred directly or indirectly in connection with the released information. This Consent and Release shall be binding on the undersigned and the heirs or parents or other legal guardian of the undersigned.

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RSRT Consent & Release Form

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