Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Apple Homecare Medical Supply, its affiliates and agents, to use my image and likeness and/or submitted pictures and/or artwork from me in its publications, calendar, advertising or other media activities (including the Internet). This consent includes, but is not limited to permission to use my name, and permission to use the above submitted picture(s) in part or in whole, in its publications, calendar, and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings.

This consent is given in perpetuity, and does not require prior approval by me.

The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

Thank you! We have received your submission.