SHARE YOUR EYES OF HOPE® STORY

Share a story about how seeing well has made a difference for a student who received a VSP® Sight for Students® gift certificate through the National Association of School Nurses.

Please do not include any Protected Health Information (PHI) about a student on this form.

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RELEASE FORM

I, the undersigned, for myself and on behalf of others and each and all of my heirs, legal representatives and assigns, and without further action or approval required, do hereby irrevocably agree and grant to Vision Service Plan, including its subsidiaries and affiliates, as well as its/their directors, officers, employees, agents, representatives and/or contractors (“VSP”), and the National Association of School Nurses (“NASN”) the following (“Release”):

  1. The unlimited right and permission to use, reuse, distribute, publish, and republish, in whole or part, my testimonial(s), statement(s), and/or image(s) in any electronic, broadcast, printed and/or other form of medium, including all Web sites maintained, operated by and/or affiliated with VSP or NASN in conjunction with its business related publicity and/or media relations activities;
  2. Waive any and all right to inspect and/or approve the finished product(s), copy(ies) and/or printed matter that may be used in connection herewith/therewith, and/or the use to which it may be applied;
  3. Release and agree to indemnify and hold harmless VSP and NASN from any and all liability, including, but not limited to, claims for libel and right to privacy, in connection with this matter.

This Release is intended as the complete agreement as to and on this subject matter.

 
 
 
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