Authorization and Release for Use of Information,

Photographs, Videos and Voice

I hereby authorize Blood Systems, Inc. and/or its member centers (collectively referred to herein as “BSI”) to use my
name (or that of my minor child or ward, or deceased family member) as well as information I provide, photographs,
videos, and voice (the “Material”) in any and all publications, broadcasts, electronic communications, news publications,
and social media channels for the purpose of creating and disseminating educational, informational, promotional,
advertising, or marketing materials to the public, or for any other lawful purpose related to the non-profit charitable
mission of BSI.

I understand and agree that this authorization is provided willingly and with no expectation or promise of payment,
compensation, or remuneration of any kind from BSI. I also understand and agree that the Material shall be the
exclusive property of BSI. I further understand and agree that the Material will not be submitted to me for my review or
approval prior to use and dissemination by BSI.

By signing this Release, I, and on behalf of my heirs, executors, administrators, assigns, and personal representatives,
hereby release, waive and discharge BSI, its members, directors, officers, employees, and agents from any and all
claims or liability arising out of or related to BSI’s use and/or dissemination of the Material. Specifically, I understand and
agree that BSI assumes no liability and will provide no compensation for claims or damages of any kind whatsoever
resulting from BSI’s use and/or dissemination of the Material, including but not limited to claims for misappropriation,
libel, slander, invasion of privacy, or lack of consent.

I understand that I may revoke this authorization at any time by sending a written request to Blood Systems, Inc. c/o
Privacy Officer, 6210 E. Oak Street, Scottsdale, AZ 85257. I understand and agree that any previously disseminated
Material will not be subject to such revocation.

For BSI’s record-keeping purposes only, please check all identifiers that apply to you.
Blood Donor Blood Transfusion Recipient Other:
Parent or Guardian of a Minor Blood Donor or Minor Blood Transfusion Recipient
Family Member of Decedent Relationship to/Name of Decedent:

Signature Date

Print First Name Print Last Name Address/City/State/Zip

Phone Email Address

For Minors (under the age of 18)

Print Minor First Name Print Minor Last Name Date of Birth

Signature of Parent/Guardian Address/City/State/Zip

Print Parent/Guardian Name Email Address

Phone Date

For BSI Use Only Initiating Location: Initial Project Name:

Blood Systems 6210 E. Oak Street Scottsdale, AZ 85257

BS 847 (Rev. 1)
MKT000