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Authorization *

I authorize Chattanooga Hope / Focus Treatment Centers to review and share my story of hope (either text or video).

The purpose of this Authorization is to obtain your consent to use and/or disclose your personal story of hope (either text or video) for community marketing, promotional and education purposes as part of the #ChattanoogaHope campaign, a public service project of Focus Treatment Centers (FTC). Specifically, I understand that the text or video story (along with any photographs) that I have shared may or may not be published and republished in any print, visual, video, electronic, digital, and/or similar media used by, representing, and/or marketing #ChattanoogaHope / FTC, including without limitation, television commercials, marketing videos, social media, newsletters, brochures, web pages, and/or other similar promotional or educational materials. Participation in these marketing, promotional, and/or educational activities is purely voluntary. I hereby grant permission to #ChattanoogaHope / FTC to use and/or disclose to the general public (or to any smaller subcategory of individuals or entities) my personal story as well as my information including my name, picture, likeness, voice, story, and other similar personally identifiable information, if I chose to provide that information. I understand that my submission may or may not be chosen for public display, and I authorize #ChattanoogaHope / FTC to make the determination whether or not to use or display my submission.

I understand and acknowledge that, in the process, individuals (both whom I may know and whom I do not know) will become generally aware of the story I have shared. I understand that I may refuse to sign this Authorization. I further understand that FTC will not receive direct or indirect compensation or remuneration (whether financial or in-kind) from a third party in exchange for using and/or disclosing my story or personal information as authorized for any purpose specified herein. I understand that I have the right to revoke this Authorization at any time by sending written notice to #ChattanoogaHope / FTC at 7429 Shallowford Road, Chattanooga, TN, 37421. My revocation, however, will not have any effect on any uses or disclosures that #Chattanooga Hope / FTC may have made before receiving my revocation notice. I understand that I have the right to receive a copy of this Authorization upon request, by sending written notice to the same address listed above.