Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Event Photo and Video Consent *

I authorize the AMD3 Foundation/Operation Walk Pittsburgh to photograph (still photo, film, videotape, or digital imagery/video), record (audiotape or digital) and/or interview me, using either an AMD3 Foundation/Operation Walk Pittsburgh staff photographer/videographer and/or reporter, or a photographer/videographer and/or reporter approved by AMD3 Foundation/Operation Walk Pittsburgh. I understand that AMD3 Foundation/Operation Walk Pittsburgh, and in some cases the organization with which it has partnered, has / shall have all legal rights to the photography / recording(s) / interview(s) and that I give up any and all rights to these organizations and will not receive any payment or compensation for the same now or in the future. I understand the photography/recording(s) / interview(s) may be used for publicity, education, public information, or paid advertising by AMD3 Foundation/Operation Walk Pittsburgh and that the photography / recording(s) could appear on AMD3 Foundation/Operation Walk Pittsburgh’s website and/or elsewhere on the Internet. I hereby release and discharge AMD3 Foundation/Operation Walk Pittsburgh, its subsidiaries, and its and their employees, agents, and representatives from any claims, liability, or results caused by the use of such photography/recording(s) and/or interview of me as provided herein. By agreeing to be interviewed about services, programs, and/or participation with AMD3 Foundation/Operation Walk Pittsburgh, I also authorize AMD3 Foundation/Operation Walk Pittsburgh, at its discretion, to interview my AMD3 Foundation/Operation Walk Pittsburgh doctor(s), nurse(s), and/or other caregivers to confirm, supplement, and/or clarify the information provided in my interview. I understand that such staff interview(s) may result in a limited disclosure of my protected health information (PHI), in the form of facts necessary to ensure the accuracy of any account based on my interview, but that no medical records will be released.

I agree

No, thank you

Contact permission *

The AMD3 Foundation and Operation Walk would love to stay in touch. By checking “yes” below, you consent to receive future emails from AMD3 Foundation and Operation Walk Pittsburgh with exclusive bone and joint health educational information and resources, as well information about our bone and joint health related educational programming and events. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes.

Yes, please. I'd like to receive exclusive bone and joint health educational information and resources, as well information about future bone and joint health-related educational programming and community events.

No, thanks. I would not like to receive exclusive bone and joint health educational information and resources, as well information about bone and joint health-related educational programming and community events.