I hereby give consent to the Wichita Cancer Foundation (“WCF”) to use written statements, images (photographs or video) or sound recordings of me and/or the person named below for whom I am giving consent (the “Patient”), or to allow an external media source or other third party to do any of the same, which may include personal information about myself and/or the person named below for whom I am giving consent that may be private or confidential in nature. I understand that such personal information, if any, may be afforded certain protections under federal and state privacy laws, and that the sharing of same to or in any public media, including radio, television, internet or print, or in WCF’s publication could result in the loss of said protections, if any. I understand that the intended use of such images and information may be for advertising, marketing, fundraising or promotional purposes of WCF. I acknowledge that this consent and authorization for release of information is being made for the benefit of WCF and without any expectation of compensation or other benefit to me, the person named below for whom I am giving consent, or our respective family, as applicable. To the extent that any benefit accrues or might accrue to WCF from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits. I hereby release and forever discharge WCF (including without limitation all officers, directors, employees and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of the disclosed images, video and information and materials described herein, and I hereby waive all rights and interest in and to such information and materials. This authorization is voluntary and cannot be revoked without first obtaining WCF’s consent, which consent can be granted or withheld in WCF’s sole discretion, and, if granted, such revocation shall be limited to the extent that action has been taken in reliance on the authorization prior to revocation. All requests to revoke authorization shall be given to WCF in writing at: Wichita Cancer Foundation, Attn: President P.O. Box 49020 Wichita, Kansas 67201-9020.