The URL can be used to link to this page

Home My WebLink AboutC14-259 Colorado Health Foundation Affidavit of Compliance AFFIDAVIT OF COMPLIANCE AND RELEASE Colorado KaleidosCOpe: Stories of a State's Health Campaign Please complete or correct the information below. Please print clearly in ink: Grantee Organization Name: EAGLE CouN-ry PueLic. HEAL-rH + ENV RoNMENT Address: Po Box 66 0 551 C312oADwAy City: LE: , Colorado; Zip: 81631 Telephone 1: 970-328-88% Telephone 2: 970-328-26Io E-mail Address: CARLY.RiETMANN1@ EAGLE CouNT\. u5 I hereby certify that I am authorized representative of the above named organization which is a current grantee in good standing ("Grantee") of the Colorado Health Foundation (the "Foundation") and I am 18 years of age or older. Grantee has complied and hereby agrees, to the extent allowed by law, to be bound by all of the terms and conditions of the Colorado Health Foundation Colorado KaleidosCOpe: Stories of a State's Health Campaign (the "Campaign") and has perpetrated no fraud or deception in connection with the Campaign. Grantee understands that it is solely responsible for payment of applicable taxes, if any, in connection with payments made in connection with the Campaign. As a condition of acceptance of the payment (the "Payment") for the use of Grantee's Submission in the Campaign, Grantee hereby releases, waives and discharges Foundation, and any of its parents, subsidiaries or otherwise affiliated corporations, partnerships or business enterprises, and their respective present and former directors, shareholders, employees and assigns (the "Released Parties"), from any and all causes of action, claims, charges, demands, losses, damages, costs, attorneys' fees and liabilities of any kind that Grantee may have or claim to have in any way relating to or arising out of the Campaign. As a further condition of my acceptance of the Payment, Grantee hereby grants Foundation permission (except where prohibited by law) to reasonably use Grantee's Submission and any information provided to Foundation in connection with such Submission, including but not limited to names, trademarks, logos, likeness and/or image, address and contents of this form without any further compensation for any future promotional activity whether or not related to the Campaign, and whether in print, audio or video, and Grantee waives all claims of invasion of privacy, defamation or other violation of rights in association therewith. Grantee hereby certifies that it is the original author, creator or owner of the Submission and/or holds all rights necessary to participate in the Campaign, and make the Submission under the terms and conditions set forth in the Colorado KaleidosCOpe: Stories of a State's Health Campaign Program Description Terms and Conditions located at www.ColoradoKaleidoscope.org. Grantee has provided all necessary Authorizations and Releases for any subject featured in the Submission. Grantee hereby grants an exclusive license authorizing the Foundation to reproduce, rebroadcast, edit, modify, transmit, bundle, sell, license, syndicate, adapt, 3357303 Glq-z6' and otherwise exploit all or any portion of the Submission without further notification or consent, and without any further obligation to compensate Grantee or any other parties. Grantee agrees that the Submission has become the property of the Foundation, and need not be returned, preserved or otherwise protected. Grantee shall retain rights to use its Submission for internal purposes and shall have the right to use the final edited work upon approval of the Foundation. Grantee agrees and acknowledges that Foundation and the Released Parties, disclaim any responsibility or liability for any loss incurred by Grantee in connection with my participation in the Campaign. By signing this document, you warrant that there has been no change in your I.R.S. tax classification as an organization described in Internal Revenue Service Code sections 501(c)(3) and 509(a)(1), (2), or (3). AGREED AND ACCEPTED: DATE: - ' 114 Q.A.01,01 Grantee's signature On this It day of Vla1 , 201 Lrbefore me personally appeared L known to be the person described in, and ho executed, the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. tniktitAA. (41 -/4tt DEBORAH LYNN C-q AC "filet Notary Public NOTARY PUBLIC TATE OF OOLORA ' MY R! r EXPORES21240016 My Commission Expires: F(-2)1-,i( -2- ,...,.+arGOogle ,1!V 1,,1, €ti ; folk; f io tt EAGLE COU Colorado KaleidosCOpe: Well and Wise Samantha Travelstead <stravelstead @coloradohealth.org> Fri, May 23, 2014 at 9:47 AM To: "carly.rietmann @eaglecounty.us' <carly.rietmann @eaglecounty.us> Cc: Sara Monge <SMonge @coloradohealth.org>, Jaclyn Lensen <jlensen @coloradohealth.org> Good Morning Carly- Thank you for submitting your video to the Colorado KaleidosCOpe. You did a great job!We are moving forward to publish the video. I wanted to outline the next steps in the process. 1. Paperwork: Attached you will find an Affidavit of Compliance and Release document that will need to be signed and notarized. You can mail this back to my attention. Our mailing address is listed in my email signature below. We need to receive this document to get started with the next steps. 2. Video production: Chance Multimedia will be producing the final edited piece. You may hear from Jessica Chance with some questions along the way. 3. Grant award: When published to our website, your organization will be awarded a $5,000 unrestricted donation award for the video. Congratulations on your successful submission! Please feel free to contact me with any questions along the way. Thank you, Samantha Travelstead Communications Assistant THE COLORADO HEALTH FOUNDATION 501 South Cherry Street 1 Suite 1100 ! Denver, CO 80246 Phone: 303-953-3673 1 Fax: 303-322-4576 Our next proposal deadline is June 15, 2014 by 5:00 p.m. Apply online at wwwColoradoHealth.org + 4 . Yp�•19&f