United Stroke Alliance®, a tax-exempt organization, also known as Retreat & Refresh Stroke Camp®, hosts camps for caretakers and survivors of stroke (the “Camp” or “Camps”).



I hereby Authorize United Stroke Alliance (“USA”) to use, publish, and/or otherwise disclose my Individual Identifiable Information, which includes but is not limited to: my name, image and likeness, voice and/or picture (my “Information") as described below. This authorization is voluntary, and no individual has coerced or forced me into agreeing to this authorization.



I understand that USA may benefit, monetarily, non-monetarily, or otherwise, from the use of my Information. I understand that I will not be entitled to any compensation for use of my Information, and I specifically release all claims against USA for the same. I understand that once my Information is received by USA, that it may be subject to use, publication or disclosure. I waive any claims of violations of federal, state, or local laws which are the result of said use, publication or disclosure.

A. Individual Identifiable Information includes, but is not limited to:

Pictures, sound recordings, videos or written statements containing my image, likeness or voice;
Interviews or statements by or about me; and
My medical situation and specific health information related to my participation in (for purposes of advancing the mission of) Camp.

B. Use and Media, my Information may be used

For publication in print, digital, or electronic media and in any other forms or forum; and
For inclusion on the USA or Camp website; and
For use in other promotional materials including by Camp sponsors and partners.


C. Right to Revoke

I acknowledge that I have the right to revoke this authorization in writing by contacting United Stroke Alliance. Any revocation will be prospective and not retrospective meaning USA will have no obligation to remove or edit out my Information from previously published media.


By checking the box below, I acknowledge and affirm the statements in this authorization form.