Community Service | Event Summary Report

Pills

  • Date Format: MM slash DD slash YYYY
  • Complete the information below to provide a summary of the event.

    This form must be submitted within five (5) business days of the event.

    If you have any questions or need further help completing this form, you can contact Robbe Bendick, Executive Director at rbendick@urpt.com.

  • Who? What? Where? When?
  • Drop files here or
    Please attach photos (list names of those in the photo, these can be used for marketing needs), photo releases, brochures, flyers or other materials affiliated with this event.
  • Date Format: MM slash DD slash YYYY
    I, the undersigned individual(s), grant Upstream Rehabilitation Inc., its affiliated companies, and event sponsors (collectively, the “Companies”) the perpetual, non-exclusive, royalty-free right and license to: • Record my participation and appearance on digital or film photography, video, audio or any other medium (collectively, the “Recordings”). • Use my name (or any fictional name), image, likeness, voice and biographical material and information in connection with these Recordings to be used only in or for the Companies written or electronic media, including, but not limited to, publications, newspapers, posters, brochures, magazines, other print media, video presentations, radio transmissions, news releases, billboards, signs, social media, websites, television advertisements, theatrical media, and electronic and paper mailings, for purposes of marketing, advertising, or fundraising (the “Purpose”). • Reproduce, distribute, publicly display and/or publicly perform, in print, electronic or any other medium, copies of the Recordings, in whole or in part. Grantor represents that he or she possesses all rights necessary to grant this permission for and in connection with the Purpose. I am voluntarily making this grant of rights. I further agree to release, indemnify, defend, and hold harmless the Companies, their respective agents, employees and designated representatives from any and all claims, damages, attorney fees, costs, fines, penalties or liability arising from or related to the Recordings.