Share My Story at the Vaccine Injury Walk 2020

October 10, 2020 | To share your vaccine injury story at the first annual Vaccine Injury Walk 2020 in Grand Rapids, please complete and submit this form and release.
BY COMPLETING THIS FORM, YOU ARE ALSO CONFIRMING MEMBERSHIP TO MICHIGAN FOR VACCINE CHOICE (MVC), A NON-PROFIT, MICHIGAN-BASED ORGANIZATION.
Injury Details

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Sharing Preferences

Your vaccine injury story will be shared at the Vaccine Injury Walk 2020 in Grand Rapids, Michigan. Your story might be printed on handouts or shown on a screen/kiosk as a slideshow (or both). It is entirely up to you how much information you want to share and how. Please select what and where we can share your story.
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Release to Use/Share Story

For valuable consideration I hereby irrevocably grant to Michigan for Vaccine Choice (MVC), its licensees, agents, successors and assigns, the right (but not the obligation), in perpetuity throughout the world, in all media, now or hereafter known, to use (in any manner it deems appropriate, and without limitation) in and in connection with the Michigan Vaccine Injury project, by whatever means exhibited, advertised or exploited: my appearance in the Vaccine Injury Project videos, still photographs of me, recordings of my voice taken or made, and my actual or fictitious name. On my own behalf, and on behalf of my heirs, next of kin, executors, administrators, successors and assigns, I hereby release the MVC, its agents, licensees, successors and assigns, from any and all claims, liabilities and damages arising out of the rights granted hereunder, or the exercise thereof.
 
IF THE STORY IS ABOUT MINORS
I am the parent or legal guardian of the minor(s) listed below. I hereby irrevocably consent to the foregoing grant and agreement. I agree to indemnify the Partnership, its licensees, agents, successors and assigns, and hold each of the foregoing harmless from any and all damages, losses and expenses resulting from any actual or purported disaffirmance or rescission of the above agreement by signatory thereto.
 
 
 
Your Contact Information

 
 
 
 
 

Description

October 10, 2020
To share your vaccine injury story at the first annual Vaccine Injury Walk 2020 in Grand Rapids, please complete and submit this form and release.