P H O T O   &   V I D E O   R E L E A S E    F O R M    F O R    M I N O R

 

I hereby grant United Healthcare Services, Inc. and its parent and affiliate companies (“United”) permission to use my name, story and likeness in a photo and/or video for the UnitedHealth Group intranet/internet sites, without payment or any other consideration.

 

I understand and agree that these materials will become the property of United and will not be returned.

 

I hereby irrevocably authorize United to edit, alter, copy, exhibit, publish or distribute this publication/photo/video for purposes of publicizing United’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

 

I hereby hold harmless and release and forever discharge United from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization, including but not limited to any claim related to the use of my likeness in any United publication.

 

I am at least 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

 

______________________________________            _________________

   (signature)                                                                                                      (date)

 

 

______________________________________            _________________

   (printed name)                                                                                              (date)

 

If individual is under the age of 18:

 

I hereby certify and represent that I am the parent or legal guardian of the above named minor, I am over 18 years of age, and that I acknowledge the terms set forth above and have read the foregoing and fully understand the meaning and effect thereof.  I agree to assume responsibility in accordance with those terms.

______________________________________            _________________

 Legal Guardian (signature)                                                                              (date)

 

 

______________________________________            _________________

Legal Guardian (printed name)                                                                             (date)