RELEASE FOR USE OF MY LIKENESS [Photo or Video]

My signature below indicates that I am authorized and freely give my consent and permission for Bristol Hospice, LLC to use my likeness for marketing purposes.

I understand that I will not be identified by name, nor will any personal health information be included with publication of my likeness. I further understand however, that my likeness associated with Bristol marketing materials may reasonably allow people to infer that I am or had been a patient of the hospice program.

I understand that I will receive no compensation for the use of my likeness and agree to release Bristol Hospice, LLC from any claims arising from or related to the use my likeness