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Media Release

I grant permission to the Cutaneous Lymphoma Foundation the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me for the purpose of publication, promotion, illustration, in any manner or in any medium related to Cutaneous Lymphoma Foundation activities. I hereby release the Cutaneous Lymphoma Foundation and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview, guest lecture or feedback, with or without my name, for the purpose of education, advertising, or publicity without restriction. I understand there is no intention to pay for the use of any images, video, article, presentation or statement and therefore I waive my right to any compensation. 
1. Please check those items that are permitted for use:
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