Application for Coco’s Eye Care Grant

Animal Model Release Form

I, , (Name of Pet Owner on behalf of Animal Model) hereby irrevocably authorize Silvie Bordeaux with Muffin’s Halo For Blind Dogs and its affiliates subsidiaries, divisions, agents, representatives, producers, reporters, employees, successors and assigns to copyright, publish, reproduce, exhibit, transmit, broadcast, televise, digitize, display, otherwise use, and permit others to use, (a) my and pet’s name, image, likeness, and voice, and (b) all photographs, recordings, videotapes, audiovisual materials, any biographical material which I may provide, writings, statements and quotations of my pet or of myself (collectively, the “Materials”), in any manner, form, or format whatsoever now or hereinafter created, including on the internet, and for any purpose, including, but not limited to, all worldwide media, an unlimited number of times in perpetuity and in the promotion, advertising, sale, publicizing and promotion of Silvie Bordeaux with Muffin’s Halo For Blind Dogs, and all its affiliates, without further consent from or compensation to me.

I hereby waive any right of inspection or approval of my appearance or the uses to which such appearance may be put and hereby agree not to assert any and all manner of liabilities, claims and demands of any kind or nature, whatsoever, in law or equity, against anyone relating to the exercise of the permissions granted hereunder.

I further represent that any statements made by me during my appearance are true, to the best of my knowledge, and that neither they nor my appearance will violate or infringe upon the rights of any third party.

Pet Owner name:

Name of Pet:

Address:

• Country:
  
• City:
  
• State:
  
• ZipCode:
  

Phone:

Your Email (required)

Veterinarian Name:

Veterinarian Number:

How Much Is Expected Expense?