I hereby grant the Center for Military Veterans Reintegration (CMVR) permission to use my likeness in a photograph or video in any and all of its publications, including web site entries, without payment or consideration.

I understand and agree that these materials will become the property of the CMVR and will not be returned.

I hereby irrevocably authorize the CMVR to edit, alter, exhibit, publish or distribute this photo for the purposes of publicizing the CMVR's services or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive my right to royalties or any other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge the CMVR from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 21 years of age and am competent to contract in my own name. I have read this release and I fully understand the contents, meaning, and impact of this release. 

You are authorizing Center for Military Veterans Reintegration (CMVR) and its Partner Agencies to use, store and share your personal, financial and health information with each other in order to assess your needs, coordinate your care and provide services to you. Partner Agencies participating in the CMVR are listed at www.nvtsi.org/community/.

This Authorization covers, without restriction, all information disclosed and re-disclosed to CMVR by you, your family, Partner Agencies including your care team, or any other person involved in your care while this Authorization is in effect. CMVR and its Partner Agencies may share your personal, financial and health information. By providing your consent, you specifically authorize CMVR to use and disclose information relating to Drug/Alcohol/Substance Abuse, Mental Health, HIV/AIDS. You agree to notify CMVR if your information changes or is incorrect. Information disclosed pursuant to this Authorization may be re-disclosed and no longer be protected under applicable privacy laws. However, your information will still be protected under our Participation Agreement with our Partner Agencies. Your refusal to sign this Authorization will not adversely affect your ability to receive health care or services from Partner Agencies.

You can revoke this authorization at any time by sending notice to CMVR at reboot@nvtsi.org, allowing a minimum of five business days to process. Revocation will not affect any information previously disclosed in reliance on this Authorization.