Fill and Sign the Dis Interment Authorization and Release Form

Release and Authorization to Use Photographs and Testimonials in Study Release executed on _________________________ (date) , by _____________________ (name of person giving release) of _________________________________________________ _________________________________________ (street address, city, county, state, zip code) herein referred to as Releasor , in favor of ____________________________________________ (name of organization doing study) , of _____________________________________________ _________________________________________ (street address, city, county, state, zip code) herein referred to as Releasee . Whereas, Releasee is conducting a clinical study (briefly describe) _________________ ______________________________________________________________________________ __________________________________________________________________________; and Whereas, this Study involves collecting and using of before and after photographs and testimonials from participants, regard marketing materials; and Whereas Releasee desires to us before and after photographs and testimonials of Releasor; Now, therefore, for and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Releasor agrees to abide by the regimen of the Study described in Exhibit A attached hereto. 2. Releasor, being above the age of eighteen (18), hereby expressly releases _______________________________ (Name of Releasee) , its licensees, agents, successors and assigns from all liability for claims and/or demands arising out of the Agreement as set forth herein. 3. Releasor hereby authorizes Releasee to record his/her picture and voice on photographs, films and audio and videotapes, to edit these recordings at its discretion, and to incorporate these recordings into movie and sound films or audio and videotapes, broadcasts (e.g., radio and television, including cable and satellite transmissions) ___________________ ___________________________________________________________________________ , or otherwise, and to use and license others to use such recordings, movie and sound films, audio and videotapes, and broadcast programs in any manner of media whatsoever, including unrestricted use for purposes of publicity, advertising and sales promotion and to use Releasor = s name, likeness, voice and biographic or other information in connection therewith. 4. Releasor further agrees to indemnify and save harmless Releasee, its licensees, agents, successors and assigns, from any and all claims and liability for damages, losses or expenses of any sort arising from the making of such recordings and their use. Releasor further acknowledges that, except for the above - stated compensation, there were no promises of any compensation for such use by Releasee or by anyone associated with Releasee and, that Releasee exclusively owns all rights to these recordings regardless of the form in which they are produced or used. Releasor warrants and agrees that he/she has read and understood the contents hereof, and that he/she has the right and authority to execute this release and indemnification. In witness whereof, the parties have executed this release and indemnification agreement at ____________________________________________________________________________ (designate place of execution) on the date and year first above written. ________________________________ ______________________________ Releasor Releasee