Check here if you give DBSA and AstraZeneca permission to contact you about the possibility of using your essay/video/art/poem/song submission in connection with future DBSA initiatives and/or unbranded AstraZeneca campaigns. Even if you check this box, your submission will not be used for these purposes unless you consent at that time.

I understand that the purpose of this program is to educate the public and inspire those with depressive symptoms of bipolar disorder or major depressive disorder, which is also called depression, by sharing stories of success in managing the symptoms of depression. I authorize DBSA, a patient-directed national organization, and AstraZeneca Pharmaceuticals LP (“AstraZeneca”)   to use, reproduce, and disclose my submission in the United States, in any media, including radio, television, print publications, video, and the Internet, which may include, but are not limited to, social networking media, for purposes of educating people on bipolar disorder and depression through educational, promotional, and commercial programs that are related to the SPEAK and Be Heard … Living with Depression program. Additionally, I understand that DBSA and AstraZeneca may contact me regarding my essay/video/art/poem/song submission to use, reproduce, and disclose my submission in the United States, in any media, including radio, television, print publications, video, and the Internet, which may include, but are not limited to, social networking media, for purposes of educating people on bipolar disorder and depression through educational programs. 

I also represent that all of my submitted statements are true, accurate, and reflect my honest opinion, and that my essay/video/art/poem/song submission is original and personally created. I also represent that I own the rights to any photographs, poems, artwork, or other materials that I submit to DBSA and AstraZeneca, and that their use of these materials will not violate or infringe the rights of any third party.  DBSA and AstraZeneca may use all or any part of my essay/video/art/poem/song, and I agree that I will not have the right to review or approve the manner in which it is used by DBSA and AstraZeneca. I understand that these statements may be edited or paraphrased to meet the requirements of copy or layout requirements, provided that the general sense is not changed. I release DBSA and AstraZeneca from any claims for royalties, residuals, or payments of any kind and I understand that I will receive no fee or other compensation from DBSA and AstraZeneca. I also agree that I will not hold DBSA, AstraZeneca, or anyone who receives permission from it responsible for any liability arising out of the use of my name, initials, likeness, photograph, or statements in accordance with the terms hereof, including what may be deemed to be any distortion or optical illusion in the finished materials.

I understand that my submission must not include any mention of specific treatments or brand/generic names of medications, or full names of medical professionals, patients, caregivers, family members, or other individuals. Any entries that include this information will be disqualified. Additionally, if I have bipolar disorder, I understand that my entry should not include descriptions of manic episodes or it will be disqualified as well.  Furthermore, I understand that in submitting my essay/video/art/poem/song my full name will not be disclosed but I may be identifiable from the medical and personal information contained in the entry. I understand that I must obtain the consent of any other person included in my submission that could also be identified, as, for example, when they are included in a video clip or artwork. I understand that once I have signed this Authorization, I cannot change my mind and cancel it.

I have read this release form carefully and fully understand its meaning and implications.