Share Your Story

Thank you so much for sharing your personal story with us. We look forward to sharing your experience with others who may find your story inspiring and helpful. 

 
Story Topic*
 
 
 
Share your story here in your own words. *
 
 

Consent & Release for Convatec to Share Your Story with Others
 
I, the undersigned, having full authority to execute this release ("Release") on behalf of myself, grant ConvaTec, Inc. all of its affiliated companies, its successors, its agents, employees, representatives, officers, directors, licensees and assigns (collectively, "ConvaTec"), the right to use, adapt, modify, reproduce, distribute, sublicense, publicly perform and/or display, in any form now known or later developed, the materials indicated below (the "Materials") specified in this Release throughout the world, and/or by incorporating such Materials into one or more works, which may include advertising promotional materials relating thereto.
 
  • Materials may include:
  • Name
  • Voice
  • Visual or Virtual Likeness (on photographs, video, film, graphics, etc.)
  • Graphics, sound effects, music, video, audio, animation, screen shots, text and other creative output as specified per project
  • Quote(s)/Testimonial(s) by you
 
 
I represent and warrant that the Materials identified above are either original to me and/or owned by me and/or I have full authority form the owner of the Materials to grant this Release. The Materials accurately represent my typical experience and results with ConvaTec's products and services, and I have disclosed to ConvaTec any material connection with ConvaTec, such as an expectation of consideration in exchange for this Release.

ConvaTec shall have an unlimited right to publish, reproduce, reuse and copyright the Materials for distribution through any media now known or hereinafter developed or invented, domestically or internationally, including multiple uses of same, in any manner and without limitation as to changes, place, duration or frequency, and without any request of prior inspection or requirements of approval from me.

I further agree that any and all such statements, endorsements, photographs, video and sound recordings or other likenesses comprising the Materials - and reproductions thereof or derivative works created therefrom - are and will remain the exclusive property of ConvaTec, including but not limited to any copyright in the materials. 

I waive any and all moral rights I may have in the Materials.

I further hereby release and discharge ConvaTec from any and all claims, actions, damages or demands whatsover which the undersigned now has or may ever have against ConvaTec, by reason of or arising out of the use, taking, publication or reproduction of the Materials, including but not limited to any and all present or future media for the purposes of advertising (including but not limited to presentation on television, print media, and electronic media). 


You may withdraw this consent at any time by contacting 1-800-422-8811 or cic@convatec.com. 


  
Please confirm one of the following:*
 
 
 
 
If you are a parent or legal guardian signing on behalf of a minor, please enter the minor's first and last name below.  The parent or legal guardian would sign their name in the e-sign field by entering in your first and last name. 

  
First Name *
 
 
Last Name*
 
 
 
Email Address
 
 
 
 
Phone Number
 
 
 
 
Please type your name here to e-sign this consent and release.*