"*" indicates required fields Date* MM slash DD slash YYYY Your Name* First Last I give permission to use my picture, video, first name, and voice (“My Likeness”).* I (“Recorded Party”) hereby grant Gynesonics, Inc. and its officers, employees, shareholders, directors, agents, contractors, representatives, licensees, successors and assigns (collectively, “Released Parties”) the non-exclusive, transferrable, perpetual license, right and permission to copyright and/or publish, reproduce or otherwise use My Likeness in any form whatsoever, including digital, video, photographs, written materials, and audio-visual recordings and to use such images or likenesses in all media including, but not limited to, broadcast, non-broadcast, commercial, non-commercial, analog and digital, national and international distribution, and all other formats, audio cassettes, transcripts, Internet streaming, including through over-the-top third party platforms (from any internet capable device, including but not limited to applications on phones, computers, game consoles, tablet computers, and other portable devices via the internet, whether now existing or later invented) and all other media and by all means whether now known or hereafter created, in perpetuity throughout the world. I acknowledge and understand these materials and My Likeness may be used for both commercial and/or non-commercial purposes and may be edited at the discretion of the Released Parties. I understand I will receive no compensation for executing this release and consent form.My Likeness may be edited or combined with other images.* I understand that My Likeness may be edited, copied, exhibited, published and/or distributed to the public. I also understand this material may be used individually or in conjunction with other media in any medium, including without limitation to print publications, digital publications, in social media and/or public broadcast for any lawful purpose. There is no time limit on the validity of this authorization and release nor are there any geographic limitations on where or how these materials may be distributed.Gynesonics has the rights to publish and distribute my story and My Likeness.* I hereby acknowledge and grant Released Parties all ownership rights in and the irrevocable right and permission to use, copyright, publish, sell, distribute, and/or promote My Likeness any and all recordings of me and/or my voice including but not limited to video, digital, audio, print, photography or written words.I do not have to sign this agreement if I'm not comfortable participating.* I understand that my participation is voluntary and that I may, at any time, discontinue my involvement before signing this document. If I choose to discontinue participation, I will notify Gynesonics in writing.What does this even mean?* I understand and take full responsibility for my involvement in this project and the risks that it may entail (be they legal, physical, or mental) and release Released Parties from any claims, demands, losses, damages, suits, and liabilities of any kind whatsoever in connection with my involvement with this project.Personal Data* I agree that my personal data will be stored within the scope of this agreement.Consent* By signing this form, I acknowledge that I have completely read and fully understand the above consent and release and agree to be bound thereby. I execute this form voluntarily and without any inducement or duress. I have reviewed the form with an attorney or I have had the opportunity to review it with an attorney. I hereby release any and all claims against any person or organization utilizing My Likeness for marketing, educational, promotional, and/or any other lawful purpose whatsoever.Permission to contact me by phone or email. I understand that someone from Gynesonics, Inc. may wish to contact me in the future for potential participation in additional video or photography work. I understand I am under no obligation to participate, and I am furnishing my email address so Gynesonics, Inc. may contact me for such purposes or for other purposes in connection with Gynesonics’ business. If I do not wish to have these contacts, I will not provide my phone number or email address.PhoneGynesonics Representatives may contact me by text message.* Yes No Rates may apply. I can opt out by replying "STOP" to any text.Your email address: Signature*NameThis field is for validation purposes and should be left unchanged.
