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Hearts & Minds - Information for ChangeSM

The End Poverty WalkathonSM
Walk to end poverty, exercise and have fun!

Dear Particiapnt,

Hearts & MindsSM welcomes your participation in the End Poverty WalkathonSM on November 8, 2009 in scenic Hudson River Park.

People of all ages are walking to show their support and raise funds for the End Poverty CampaignSM, the world's most ambitious and achievable program to help end extreme poverty, and to support Hearts & Minds other public service work.

Who we are
Founded in 1996, Hearts & Minds Network, Inc. is an all-volunteer, nonprofit 501(c)(3) tax exempt organization that promotes self-help, volunteering and community service. Our work empowers people all over the world to address poverty, the environment, human rights, democracy, addictions and other important issues.

We use mass communications to inspire, motivate, inform and empower as many people as possible - in New York City, nationwide and beyond.

Our website - www.change.net - provides resources, links and practical advice that enable millions of people worldwide to help themselves and others in need. We bring together people of all ages to help solve persistent social problems.

The release form
We plan to interview, film and/or photograph some of the participants to raise awareness of poverty and other important issues, and also to support and promote Hearts & Minds' public service.

Please carefully review the permission form below. If you have any questions, feel free to ask. If agreeable, please fill out and sign. If you are under 18 years of age, your parent or legal guardian must also read and sign the form.

We appreciate your interest in helping us help others.

Thank you.


Bill Blackman

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Hearts & Minds - Information for ChangeSM

End Poverty WalkathonSM

Release Authorization and Agreement

This is an Agreement between Hearts and Minds Network, Inc. and all individual(s) specified below.

I, ______________________________, am at least 18 years old. I am also the parent/legal guardian of any other individuals listed below.

I hereby give full permission for myself and my child(ren)/ward(s) (referred to here as "we" and "us") to participate in programs run by Hearts and Minds Network, Inc., its partner organizations, its licensees and assignees (collectively referred to as "Hearts & Minds" and "them").

We give Hearts & MindsSM permission to use our  name and interviews, photography, film, audio and video of me (or in which  we may be included) taken during the events (collectively, the "Released Words and Images") in any promotional materials.

We also grant irrevocable and unrestricted right to use and publish Released Words and Images, for editorial, trade, advertising and any other purpose in any manner and medium; to alter the same without restriction; and to copyright the same.  We hereby release Hearts & Minds and their legal representatives and assigns from all claims and liability relating to said Released Words and Images. Hearts & Minds reserves the right to decide the manner in which any credit is provided.

We grant to Hearts & Minds the foregoing exclusive rights regarding the Released Words and Images in any and all media now or hereafter known, including but not limited to any print publication, video, film, telecast, exhibition, website and digital reproduction.

The Released Words and Images can be used for illustration, art, promotion, public relations, fundraising, advertising, trade, stock photography, promotion of any goods or services, or any other purpose whatsoever.

We acknowledge that Hearts & Minds is and shall be considered the author of all Released Words and Images under all applicable copyright laws whether foreign or domestic and owns and shall own all Released Words and Images in all forms. If there is a conflict between any applicable laws or an absence of comparable laws, those of the United States of America will apply.

If anyone makes use of our words or images in a way that is not authorized by Hearts & Minds and that we find deeply objectionable, we can take appropriate legal action against only those unauthorized parties. We will continue to hold Hearts & Minds completely harmless and free of liability, and will take no actions against Hearts & Minds, nor require its participation in our independent legal actions.

We are in good health and  We know that  We can drop out any time during the Walkathon. We hereby release, discharge and agree to hold Hearts & Minds harmless from any liability resulting from any injury or accident, regardless of cause, in which we are involved before, during or after any events or other meetings with Hearts & Minds.

In addition to the absolute and unqualified release from all liability, We hereby represent that we are physically capable of participation in this event. We will observe all applicable laws, traffic and event rules and conduct ourselves in a safe and prudent manner while participating in Hearts & Minds events. We understand that we are free to discontinue participating at any time and that decision is our responsibility.

We hereby consent to and permit emergency treatment in the event of injury or illness while participating in this event.

If any disputes arise regarding this Agreement, both parties will make every reasonable effort to resolve them by mutually acceptable, impartial conflict resolution. If they cannot agree on an arbitrator, all conflicts shall be resolved according to the laws of New York State and shall be brought before the courts of that state in a location convenient to the Hearts & Minds office.

This Agreement constitutes the entire Agreement between the parties with respect to the subject matter hereof and shall supersede all previous communications, representations, understandings and agreements, either oral or written, between the parties or an official or representative thereof. This Agreement can only be modified in writing and only when signed by both parties.

This entire Agreement shall inure to the benefit of Hearts & Minds, its agents, licensees, representatives and assigns and shall be binding upon us and our heirs, legal representatives, heirs and assigns. If any part of this Agreement is found to be unenforceable, all remaining provisions shall remain in force.

WE HEREBY AFFIRM that we have read carefully this Release Authorization and Agreement to Hold Harmless prior to its execution. We had an opportunity to have all of our questions answered completely and to fully consider this Agreement. We completely understand and fully agree to the contents thereof.

I, the one who signs the first line below, am at least 18 years of age and have the legal right and authority to contract for this Agreement for myself and any minors named herein. We hereby release Hearts and Minds Network, Inc. from any claim or liability whatsoever in connection with our participation in any activities with Hearts & Minds, the use of artwork, film, other intellectual property and accompanying disclosures.

Please print:

My full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Apt. #: |__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__| State: |__|__| Zip Code: |__|__|__|__|__|

E-Mail (optional): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|__|

Phone number(s): |__|__|__| - |__|__|__| - |__|__|__|__| and |__|__|__| - |__|__|__| - |__|__|__|__|

Signature: _______________________________________________

My age (not required if I am 18 or older): |__|__|   Date: ____/____/0__

If you do not want you or your participants to be identified by last name, place your initials here: |____|

Participant(s) under age 18 (please print):

1. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

2. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age:|__|__|   Signature: _______________________________________________

3. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

Feel free to Contact Us if you have any additional questions or concerns:

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5 (USA)
E-mail: [email protected]

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This web page and entire website Copyright: 1997 - 2015 by Hearts and Minds Network, Inc. http://www.heartsandminds.org/poverty/ok.htm - online April 17, 2008, latest changes May 4, 2008