CURE SYNGAP1 Media Consent and Release for Adults and Minors

Complete this section only if you are signing for yourself.

Adult Media Consent (18+): I consent to being photographed, recorded, or otherwise included in audio, video, photographic, or digital media by CURE SYNGAP1 or its authorized representatives. I grant CURE SYNGAP1 a non-exclusive, royalty-free, worldwide right to use, reproduce, edit, adapt, display, and distribute such recordings or images, in whole or in part, in any format, for lawful organizational purposes. These purposes include, but are not limited to, education, advocacy, research awareness, grant and funding materials, event documentation, public awareness efforts, digital platforms, websites, publications, reports, and presentations. I understand that: Participation is voluntary and I may decline to answer any question or stop participation at any time. The recordings or images will not be sold or licensed for commercial purposes and will not be used to imply my endorsement of any product or commercial entity. I will not receive compensation for participation or for the use of these materials. I waive any right to inspect or approve the finished media or any accompanying text in which my likeness appears. I release and hold harmless CURE SYNGAP1 and its agents from any claims arising from the use of these recordings or images, including claims related to alteration, distortion, or publication. I understand that I may withdraw consent for future use by contacting CURE SYNGAP1 at info@curesyngap1.org. Withdrawal of consent does not apply retroactively to materials already published, distributed, or submitted. I represent that I am at least eighteen (18) years of age and legally able to provide this consent.

Complete this section only if you are a parent or legal guardian signing on behalf of a minor or dependent. I am the parent or legal guardian of the minor or dependent named above. I give permission for my child or dependent to be photographed, recorded, or otherwise included in audio, video, photographic, or digital media by CURE SYNGAP1 or its authorized representatives. I grant CURE SYNGAP1 a non-exclusive, royalty-free, worldwide right to use, reproduce, edit, adapt, display, and distribute such recordings or images, in whole or in part, in any format, for lawful organizational purposes. These purposes include, but are not limited to, education, advocacy, research awareness, grant and funding materials, event documentation, public awareness efforts, digital platforms, websites, publications, reports, and presentations. I understand that: – Participation is voluntary and my child or dependent may decline to participate or stop participation at any time. – The recordings or images will not be sold or licensed for commercial purposes and will not be used to imply endorsement of any product or commercial entity. – No compensation will be provided for participation or use of these materials. – I waive any right to inspect or approve the finished media or any accompanying text in which my child’s or dependent’s likeness appears. – I release and hold harmless CURE SYNGAP1 and its agents from any claims arising from the use of these recordings or images, including claims related to alteration, distortion, or publication. I understand that I may withdraw consent for future use by contacting CURE SYNGAP1 at info@curesyngap1.org. Withdrawal of consent does not apply retroactively to materials already published, distributed, or submitted. I represent that I am at least eighteen (18) years of age and legally authorized to provide this consent on behalf of the minor or dependent.