RMHC of the Southwest Grant, Assignment, Release and Waiver

I hereby forever grant to (i) Ronald McDonald House Charities, Inc., its affiliates, subsidiaries, franchises, advertising and promotional agencies, and their respective agents and representatives, any of its Chapter organizations (defined as an entity having the right to use Ronald McDonald House Charities, Ronald McDonald House, Ronald McDonald Family Room, and/or Ronald McDonald Care Mobile, or other trademarks for charitable purposes) (collectively, "RMHC") and (ii) all of RMHC's corporate partners (collectively, the "Partners"), including, but not limited to, McDonald's Corporation, its affiliates, subsidiatires, franchises, advertising and promotional agencies, and their respective agents and representatives (collectively, "McDonald's), and together with RMHC and the Partners, the "Grantees"), the irrevocable, royalty-free, unrestricted worldwide right to use, publish, display, broadcast, edit, modivy and distribute materials bearing my name, voice, image, likeness and/or any other identifiable representation of myself (collectively, "My Likeness"). These materials may appear in any form, style, color or medium whatsoever now known or later developed (including, without limitatin, photographs, videotapes, videos, digital media, films, sound recordings, software, drawings, prints, broadcast, internet and electronic media.) The Grantee's use of My LIkeness will be limied to use involving raising awareness of or for support of RMHC.

I agree that all materials containing My Likeness (including, without limitation, all negatives, plates and masters of any photographs, videos, recordings, files, prints or tapes) shall be and remain the sole and exclusive property of the Grantees, and I hereby assign any right I may have acquired in or to such material to the Grantees. I hereby release and forever discharge the Grantees from any and all claims, liabilities and damages relating to the use of My Likeness. I hereby waive any right I may have to inspect or approve the finished materials or any part or element thereof that incorporates My Likeness. I acknowledge and agree that if I committed or commit any act of have been or shall become involved in any situation or occurrence tending to bring myself into public disrepute, contempt, scandal or ridicule, or tending to shock, insult or offend the people of this nation or any class or group thereof, or reflecting unfavorably upon the reputation(s) of any Grantee (collectively, an "Act"), then RMHC reserves the right to immediately cease use of My Likeness without further notice due to me. I further understand and agree that any determination with respect to an Act shall be at the sole discretion of RMHC and shall be conclusive in all respects. I have agreed to the above in consideration of the opportunity given to me by RMHC and/or McDonald's to appear in these materials. I acknowledge that I have fully read and understand this document and that I have had any questions regarding its effect or the meaning of its terms answered to my satisfactions. I certify that I am at least 18 years of age, unless this doocument is also signed by my parent or legal guardian.

Name *

First

Last

Affiliation to RMHC *

Guest Family
Volunteer
Donor
Staff

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Today's Date *

MM/DD/YEAR format

Signature *

Consent for a Minor's participation:

I represent that I am parent or legal guardian of the person(s) identified above, who is/are minor(s). I understand the above and consent to the use of their Likeness as set forth above.

Minor #1 Name

First

Last

Minor's Date of Birth

MM/DD/YEAR format

Minor #2 Name

First

Last

Minor's Date of Birth

MM/DD/YEAR format

Minor #3 Name

First

Last

Minor's Date of Birth

MM/DD/YEAR format

Signature