By completing and submitting this form, I give to Centra, its employees, physicians, volunteers and other people officially working on behalf of Centra, consent and permission for an interview and/or photograph(s), still or film, for purposes of publication in newspapers, magazines or other printed media, or for broadcast by means of video, motion picture, radio, television or internet transmission. I relieve and agree not to hold Centra liable for the interviewing and photographing, and subsequent publication or broadcasting. I understand that the interviewing and photographing are being carried out with my consent, and I assume responsibility for my consent.
