Photo Consent Form

Photo Description (include names of individuals as well) Example: People shown in photo from left to right are [list first and last name of each individual]

In return for good and valuable consideration, receipt of which is hereby acknowledged, I agree as follows:

I grant to Centene Corporation, its subsidiaries, agents, licensees, successors and assigns (“Centene”), the right to use my name (in whole or in part), voice, and appearance; and the right to use audio/visual recordings, verbal recordings, written statements, pictures, portraits, photographs, and any other image or likeness of me, biographical or occupational descriptions or phrases regarding me, and incidents or anecdotes concerning me (the “Material”), in any and all manner and media now known or later developed and for all types of advertising, publicity, promotion and other trade purposes, now and for any future use, throughout the world in perpetuity.

I agree that Centene is the owner of all copyrights and other intellectual property rights in the Material throughout the world and may edit, reproduce, prepare derivatives of, distribute, perform, display, transfer and copyright the Material in its sole discretion without additional consent from me or payment to me. I expressly release Centene from any and all claims which I have or may have for invasion of privacy, defamation or any other cause of action arising out of any and all uses of the Material.

No promise or representation which is not expressed in this Consent and Release has been made to me, and I have read this document, understand it and am signing it voluntarily.

First Name *

Last Name *

Date *

By typing in my name, I am attesting that I am the individual in question and am providing my consent for this authorization.

If a Minor:

I certify that I am the [parent/legal guardian] of the individual who executed this Consent and Release. Acting both for myself individually and on behalf of said individual, I consent to the execution of this Consent and Release by said individual and the grant of right made therein.

By typing in my name, I am attesting that I am the individual in question and am providing my consent for this authorization.

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Date