Additional Details/Detalles adicionales

My response indicated by checking a box below indicates that I permit and authorize Club 21 Learning and Resource Center in Pasadena, California, and employees, agents, and personnel who are acting on behalf of Club 21, to use the following for purposes related to the overall mission of the organization, including publicity, marketing and promotion of Club 21 without compensation to me. I understand the above may be subject to reasonable modification or editing and may be reproduced and distributed by means of various media, including but not limited to publications, video or digital presentations, television broadcasts/rebroadcasts or radio transmissions/retransmissions, news releases, mail outs, billboards or signs, brochures or Web sites. I waive any right to inspect or approve the finished product, or any material in which Club 21 may eventually use my image, video, words, artwork, and information or other items indicated above. I understand that while Club 21 will endeavor to use the above in accordance with standards of good judgment, Club 21 cannot warrant or guarantee that any further dissemination of the above will be subject to Club 21 supervision or control. Accordingly, I release Club 21 from any and all liability related to dissemination of my video, image, words, information, and participation as a member and other items indicated above. This consent and release shall be binding upon my heirs, successors, assigns and legal representations. I have read this document and fully understand its contents.

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