Consent and Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Boomers Today, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:

Permission to interview, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

Permission to use my name and Organization/Company; and

Permission to use quotes from the interview(s) (or excerpts of such quotes), photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in publications and other print media, on television, radio and electronic media (including the Internet), and/or in mailings for educational and awareness.

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