The above named Guest does hereby consent to the recording and distribution of reproduction(s) of the Guest's voice and performance as part of the media program entitled “Recovery Stories Have Power” (herein referred to as the "Program"). This is to confirm that the undersigned has agreed to be interviewed or otherwise participate in the Program, a production of the Faces & Voices of Recovery.

As a condition of publication/broadcast and for no monetary compensation, Faces & Voices of Recovery requests the non-exclusive worldwide rights to reproduce, distribute, and sell your oral and/or video presentation, in whole or in part, in any media, as part of this Program published under the auspices of Faces & Voices of Recovery and to license these rights to others, in perpetuity. Faces & Voices of Recovery shall have the right to edit and/or transcribe your presentation.

You also grant Faces & Voices of Recovery the right to use your name, biography and likeness in connection with the Program.

You warrant that your presentation is original with you, that publication/broadcast will not infringe on the rights of others, and that you have full power to grant this license. Should your presentation/broadcast incorporate copyrighted materials of others, you warrant that you have obtained such permission from those parties for publication/broadcast by Faces & Voices of Recovery, consistent with this Agreement.

If the foregoing terms are satisfactory, please sign and date this agreement below and return it to the Program coordinator. Execution of this Agreement does not obligate Faces & Voices of Recovery to publish your presentation or other materials.

I hereby consent to the use of my oral and/or video presentation as described and agree with the provisions of this release form.