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I hereby authorize Steps2Walk, Inc. and its employees, agents, and assigns, to use my image, name, photograph, likeness, and protected health and medical information, or that of my below named minor child, for the purposes of explaining, promoting, and advancing the charitable work of Steps2Walk, Inc., including fundraising purposes.  This authorization is valid on the date signed below and does not expire unless revoked by me in writing.

I understand that information used or disclosed under this form may be re-disclosed by the recipient and that such information would no longer be protected by law.

I have the right to refuse to sign this Authorization Form.  If signed, I have the right to revoke the authorization, in writing at any time.  I understand that any actions already taken in reliance on this Authorization Form cannot be reversed and that my revocation will not affect those actions.

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