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2024 Resident Consent Form

I hereby unconditionally consent to the unrestricted use by Life Enriching Communities and its affiliated entities, officers, directors and employees (collectively “LEC”), their respective successors, assigns, agents and others authorized by LEC, of the following for identification, advertising, publicity and other purpose in connection with trade or commerce, including without limitation LEC websites and/or social media applications, and without any geographical limitation or any limitation as to the frequency of use: (1) my name; (2) my picture(s), portrait(s) and likeness(es), and any part or parts thereof, in any form, including the production of a videotape or film, whether retouched, modified, superimposed or otherwise; and/or (3) my statement(s) made or with such changes in language as do not materially change the substance of such statement(s).

I hereby acknowledge and consent to the use, disclosure or implication of my individually identifiable health information (Protected Health Information) as described above. By signing below, I hereby unconditionally consent to such use and disclosure. I understand that: (i) this authorization is voluntary and I may refuse to sign it; (ii) I am not required to sign this authorization as a condition of receiving treatment or payment for health care; and (iii) information that is used or disclosed pursuant to this authorization may be redisclosed by the receiving person or organization and, upon redisclosure, no longer be protected by federal privacy law. I further understand that I may revoke this election at any time prior to its expiration date by sending a written revocation notice to the LEC Privacy Officer, 6279 Tri-Ridge Blvd., Suite 320, Loveland, OH 45140. Any revocation will not have any effect on any actions that LEC took before it received the revocation notice.

I hereby waive any right to compensation and any right that I may have to inspect or approve any use or application of said material, and I hereby release LEC and all persons acting by its authority from any or all claims and liabilities of any kind by reason of such use or application. I also understand that LEC may decide not to, and is under no obligation to, use any of the material covered by this release and may elect not to exercise its rights hereunder.

I represent and warrant that I have every legal right to give this release and that it does not in any way conflict with any existing commitments or other representations on my part. This consent and release expires three years from the date of my signature below, unless previously revoked by me in writing.

September 23, 2024

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July 9, 2024 10:48 am EDT

2024 Resident Consent Form Uploaded by Janelle Behm - mktrequest@lec.org IP 192.24.138.188