Without expectation of compensation or other remuneration, now or in the future. I hereby give my consent to GPVM and CPSA or its affiliates, its producers and agents, to use my words, image and likeness and/or any interview statements from me in its advertising or other media activities (including the internet or publication). This consent includes, but is not limited to:
(A) Permission to interview, film, photograph, tape, publish or otherwise make a video reproduction of me and/or record my voice and image.
(B) Permission to use my name; and
(C) Permission to use quotes from the interview(s), submitted words (or excerpts of such quotes), the film, photograph (s), tape (s), publish (s) or reproduction(s) of me, and/or recording of my voice, or written words in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio, books and electronic media (including the internet), in theatrical media and/or in mailings for educational and awareness.
