Play It Back Songs Music Interest Form

To be eligible for this program, participants must have been diagnosed with cancer between the ages of 15-39 and must currently be within this age range. 

Para ser elegible para este programa, los participantes deben haber sido diagnosticados con cáncer entre las edades de 15 a 39 años y deben estar actualmente dentro de este rango de edad.

If under 18 form must be signed by a parent or guardian - Menor de Edad

Photograph/Filming and Release of Liability Form

PHOTOGRAPHY AND FILMING RELEASE By filling out and submitting this form, the participant listed below (“PARTICIPANT”) consents to film footage and/or the participant's photograph and details being published on Teen Cancer America’s website, brochure, publications, marketing/advertising, Teen Cancer America related stories for newspaper, television, radio, magazines, social media and online publications.

This release, electronically dated for today, is made in reference to the Teen Cancer America and is made by and between the participant listed below (“PARTICIPANT”), on the one hand, and Teen Cancer America, on the other. This release pertains to any and all risks associated with entering the PREMISES, including but not limited to cooking, or walking on the streets to and from the PREMISES, which may not be safe, engaging in any of the events or activities on the PREMISES, without limitation (together, “ACTIVITIES”).  Additionally, I understand that these ACTIVITIES will be filmed and that I may appear in photos, videos, or other audiovisual recordings (“RECORDINGS”) that will be owned by Teen Cancer and/or its affiliates, and that this release gives Teen Cancer America perpetual the right to use my name and likeness in connection with those RECORDINGS, without limitation. This release is to be signed by all persons entering the PREMISES and/or participating in the EVENT(S).

         I acknowledge that I have been informed of the risks involved in engaging in any of the above-named ACTIVITIES, and if I choose to do so, I do so at my sole risk.  I acknowledge, understand, and agree that:

1.  Engaging in the Activity(ies) may cause me to be exposed to the risk of injury from such activity(ies) may be significant, including without limitation the potential for harm, physical and mental injury, emotional distress, death, disability, disfigurement, physical and mental illness, and loss or damage to person or property.  I knowingly and freely assume all such risks, both known and unknown, even if arising from negligence of the persons released from liability below and assume full responsibility for my participation in the Activities. I understand that Teen Cancer America, and each of its respective assigns, heirs, agents, and designees, shall not be responsible for any harm, injury, or damage that I may suffer as a result of my choosing to partake in such Activities.

2.  I acknowledge that no representations or warranties of any kind whatsoever have been made to me regarding entering the PREMISES, or participating in the EVENT or ACTIVITIES, and walking to and from the ACTIVITIES or PREMISES. If I choose to do so, I will do so entirely at my own risk.

3.  I, for myself and my heirs, next of kin, spouse, guardians, legal representatives, executors, administrators, successors, and assigns (the “Releasing Parties”) HEREBY UNCONDITIONALLY AND IRREVOCABLY RELEASE, FOREVER DISCHARGE, AND HOLD HARMLESS TEEN CANCER AMERICA, and each of its agents, affiliates, employees, contractors, assigns, heirs, designees, and successors (the “Released Parties”) to the fullest extent permissible under law from any and all manner of liabilities, claims, and demands of any kind or nature whatsoever, in law or equity, whether known or unknown, and whether at my instance or at the instance of any third party, related to any harm, loss, physical or mental injury, physical or mental illness, emotional distress, death, disability, disfigurement, or damage to person or property that I or any third party may suffer arising out of or pursuant to the negligence of the Released Parties or otherwise, or arising out of my preparation for or participation in the ACTIVITIES or other activities associated with the ACTIVITY(ies), whether occurring before, during, or after my actual participation in the ACTIVITY(ies), whether such loss or damage be direct, indirect, consequential, or otherwise (the “Released Claims”).

4. I irrevocably agree to defend, indemnify, and hold harmless each of the Released Parties from and against all liabilities, claims, and demands of any kind or nature whatsoever, in law or equity, whether known or unknown, by whomever asserted, with respect to (a) any and all Released Claims; and (b) any conduct in which I may engage that has not been acknowledged and authorized by TEEN CANCER AMERICA in writing; and against any claims brought by any third parties which may participate in the ACTIVITIES by virtue of my allowing them on the PREMISES.

* If you are under 18, please have your parent/guardian fill out the information below.

By filling out the information below and submitting the form, you agree to the terms outlined in the form above titled Photograph/Filming and Release of Liability Form.

Teen Cancer America respects your privacy and values the trust you place in us when giving personal information. Please review the questions below and make sure your questions are answered before signing.


Will my personal medical information be disclosed?

It is your choice and that of your caregivers (if under 18) to disclose any medical Information. Teen Cancer America will not share any personal medical information without your permission.


What happens after my photos go public?

Once stories, photos, audio, and videotape enter the public domain, it’s important to understand that other outlets are free to use them, too. For example, photos and stories in the Los Angeles Times are often picked up by news wires, reprinted by other newspapers and websites, and broadcast by radio and television stations.

Before you sign this form, make sure you are comfortable with the amount of public recognition you may receive. Teen Cancer America cannot control how -- or for how long -- other outlets use or distribute your information, photos and videotape for future stories. We also cannot guarantee that other organizations will not display your publicized images or information on their own websites.


Can I withdraw my consent? 

I understand that my consent can be withdrawn at anytime in writing to Teen Cancer America at 11845 West Olympic Blvd. STE 775W in Los Angeles, CA , 90064 or by e-mailing If my images have already been utilized prior to my withdrawal, I understand that it is a possibility that images may not be removed.