FISHER HOUSE GUESTS
HELP US HELP YOU, PLEASE FILL OUT THE WELCOME FORM BELOW WHICH INCLUDES THE PHOTO RELEASE CONSENT DISPLAYED BELOW TO BE ELIGIBLE FOR PATRIOT MAGAZINE, NEWSLETTER AND SOCIAL MEDIA.
*This information will be used for grant and funding purposes to support the West Palm Beach Fisher House.
WE ARE GRATEFUL FOR YOUR SUPPORT!
Thank you for your service!
PHOTO RELEASE FORM
To be eligible for the Patriot magazine we must have your consent.
FISHER HOUSE FOUNDATION AND
FRIENDS OF FISHER HOUSE, INC.
MEDIA CONSENT
CONSENT FOR USE OF PHOTOGRAPHY, PICTURE, VIDEO, QUOTES AND/OR VOICE
I hereby voluntarily and without compensation grant to Fisher House Foundation AND Friends of Fisher House, Inc. the irrevocable and unrestricted right to use and publish my name, photography, photographs, indirect and direct quotations, video footage and/or voice recordings of me, or in which I may be included, for print publications, electronic reproductions, social media and/or promotional materials – or any other purpose and in any manner or medium relating to the promotion of Fisher House. In addition, I grant my permission to alter the same without restriction; and to copyright the same if required. I hereby release Fisher House, the photographer, the videographer, and the advertising agency from all claims and liability relating to said materials. I understand that my consent or refusal to consent to this agreement will have no effect on my eligibility for Fisher House programs now or in the future.
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West Palm Beach VA Healthcare System
7305 N. Military
Trail
West Palm Beach, Florida 33410-6400
https://www.va.gov/west-palm-beach-health-care/
Local VA Connect: 1-561-422-6838
Toll Free VA Connect: 1-866-383-9036
VA Tel-Care Nurse (After 4:00 P.M.): 1-877-741-3400