I hereby authorize, license, and consent to the unrestricted use and publication by Passy-Muir, Inc. (“Passy Muir”) of the picture or videotape taken of me, with or without my name, title and quotes, with the following limitations (please describe any limitations):

Limitations:
I also understand that Passy Muir may place such names, statements, quotes, stories, likeness, images, films, videotape, or photographs on the Internet.

I understand that Passy Muir is relying on my consent and will expend significant time and resources creating and preparing materials based on this Agreement and Consent.

Except as specifically stated above, I hereby waive any and all rights I may have with respect to any names, statements, quotes, stories, likeness, images, films, videotapes, or photographs that I have provided to Passy Muir, and all images or works created from them. Except as specifically stated above, I hereby waive any and all rights I may have with respect to any photographs or videotape taken of the Subject by Passy Muir, and all images or works created from them.

Without limiting the generality of the foregoing, I specifically waive: (i) any rights I may have to be paid or otherwise compensated for the use of such names, statements, quotes, stories, likeness, images, films, videotapes, or photographs that I have provided to Passy Muir; (ii) any rights I may have to control the manner of use of such names, statements, quotes, stories, likeness, images, films, videotapes, or photographs that I have provided to Passy Muir; and (iii) any rights I may have to inspect or approve the finished images, video, internet website, or printed matter that may be used in connection with the names, statements, quotes, stories, likeness, images, films, videotapes, or photographs that I submitted to Passy Muir, or that relate to the Subject and were created by Passy Muir.

I understand that due to space and other editing considerations, the content may be edited or altered by Passy Muir.

I understand that Passy Muir is not obligated to use such names, statements, quotes, stories, likeness, images, films, videotapes, or photographs unless Passy‐Muir decides in its sole discretion to do so.

I am over 18 years of age, and I am authorized to sign this Agreement and Consent.