Confirmation: My Go Further Story

Thank you for sharing your story with us.

Each month we will highlight different “My Go Further Stories” on our various social media channels. To follow along and see your story, be sure to like us on Facebook, Instagram and Twitter.

Terms and Conditions

I give Good Shepherd Rehabilitation Network (“GSRN”) permission to share my story, including photographs and/or video footage of me, for fundraising, educational or promotional purposes. I understand that Good Shepherd may publish this content online, and in print materials, and it may be revised and used in part or in its entirety.

I authorize the release of any health information associated with my experience and authorize the staff of Good Shepherd to discuss this information with physicians and other staff, as necessary, to verify the accuracy of, or supplement, the information. I understand that my health information may no longer be confidential.

I understand that I may revoke this consent at any time, in writing, and that no further information will be shared; however, such revocation will not affect any actions taken prior to the revocation.

I agree that any photographs and/or recordings will remain the property of GSRN. I also agree that the personal satisfaction derived from my cooperation in furthering the education, marketing, fundraising and scientific objectives of GSRN is sufficient consideration for the activities authorized hereunder, and waive any payments, royalties or other compensation, except any wages or salary to which I may otherwise be entitled.

I hereby release GSRN, its affiliates, components, principals, employees, and agents from any and all claims and liability arising in connection with the taking, use, editing publication and/or distribution of my story/image/recording.