I authorize NAINA to permit its representatives to use my photo. I understand that NAINA retains no control of the use of any photograph that is released.

I understand, however, that once information and materials are released to the public information media – including but not limited to television, newspaper, magazine, radio and the internet, NAINA no longer has control over their use. I hereby release and discharge NAINA and their assigns or representatives from any and all claims and demands arising out of or in connection with the use of the photographs, videotape, audiotape and/or release of protected health information.

I will receive no compensation for consent for the release of this material.

I have read this form and fully understand the contents. I agree to be bound by this consent form. I acknowledge and represent that I am 18 years of age or older and have the right to contract in my own name or that I am legally authorized to sign this form for the participant.

The Author is responsible for proper citation for references used in scholarly work.

I am not using any copyrighted images, if used, author is fully responsible for copyright related matters.