THIS IS A RELEASE OF LIABILITY. BY ACCEPTING BELOW, I AM
AGREEING TO RELEASE THE BOETTCHER FOUNDATION (THE "FOUNDATION") AND
OTHER PARTIES FROM LIABILITY. I HAVE THEREFORE BEEN ADVISED TO READ THIS
DOCUMENT CAREFULLY. In consideration for the privilege of participating in the
Boettcher Foundation Scholarship Program (the "Program"), I (on behalf
of myself and my family, heirs, legal representatives, executors,
beneficiaries, successors and assigns) hereby authorize the Foundation, and any
other person or entity associated with the Foundation, to use now or any time
in the future my name, likeness, voice, school, title, personal background,
educational information, photograph and/or videotaped image for educational,
publicity or promotional purposes relating to the Program. I understand that
such use may include, but shall not be limited to, marketing materials whether
in print, online, published or verbal. I understand that I will not receive
compensation or royalties now or in the future for the use of my likeness and
information. In addition, I agree to release and hold harmless the Foundation;
members of its Board of Trustees; and its officers, employees, members,
volunteers and agents (the "Released Parties"), from, and to
discharge and waive, any and all claims, demands, losses, damages and
liabilities (whether known or unknown, foreseen or unforeseen, future or
contingent) with respect to any injury arising from such publication, including
any cause of action for libel, slander, defamation of character or invasion of
privacy.
I have read this Authorization and Release and understand
its terms. I further represent that I am a minor in my state of residence and
that my parents or guardian have agreed to this form in the "Consent"
section below.