Story Release Form

For consideration which I acknowledge, I consent to the use of my statements and grant to the Fisher Center for Alzheimer’s Research Foundation, licensees and successors the right to copy, reproduce, and use all or a portion of the statements my story for incorporation in Fisher Center’s website, magazine and other publications.

I grant the use of all or a portion of the my story in any of Fisher Center’s derivatives in all forms and media electronic, print and other, including advertising and related promotion throughout the world and in perpetuity. I grant the right to use my name or pseudonym in connection with all uses of my story.