AMERICAN MEDICAL ASSOCIATION CONSENT AND RELEASE

AMERICAN MEDICAL ASSOCIATION

CONSENT AND RELEASE

I have read this Consent and Release form, or someone has read this Consent and Release form to me, and I understand its terms. I have been given the opportunity to ask all of the questions I have, and all of my questions have been answered to my satisfaction.

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby give my consent and grant to the American Medical Association (“AMA”) and its agents, the unlimited, perpetual, worldwide right to (i) produce, reproduce, print, publicize, advertise, publish, edit, display, copyright, transmit, use, and distribute, in print and/or electronically, including posting to the Internet, the personal story of my unique experience(s) with the United States health care system (“My Story”); and (ii) use my name, video, story, and other personal data I provide to the AMA below (“Personal Information”) in connection with My Story, and in any advertising, publicity, and/or printed matter that may be distributed or transmitted in connection with My Story. I acknowledge, however, that AMA is not obligated to use any of my Personal Information in connection with My Story.

I hereby waive (i) any right to inspect or approve the use of My Story and my Personal Information by AMA, and any advertising, publicity, or other print or electronic matter that may be used in connection with My Story and the Personal Information; and (ii) all moral rights including, but not limited to, the right of attribution.

I hereby assign to the AMA any and all rights I may have, including copyright, in and to My Story. I acknowledge that the AMA shall retain all right, title, and interest in and to My Story, including copyright.

I hereby release the AMA, and its officers, directors, trustees, employees, agents and all persons acting under its authority or those for whom the AMA is acting, from all claims and liability caused by or otherwise arising from AMA’s use of My Story and the Personal Information, and from any and all claims and liability of every kind relating to the production, reproduction, publication, editing, copyright, use, transmission, distribution, advertising, publicity, or display of My Story and the Personal Information for the purposes described herein.

I hereby represent that the following statements are true and accurate:

• The video and/or message submitted as My Story is of me and not any other individual

• The video submitted as My Story was taken within thirty (30) days of the date I agreed to this Consent and Release.

• The content of My Story is an accurate reflection of my own experience with the United States health care system.

• I am at least 18 years of age.

• My Personal Information is true as of the date agreed this Consent and Release.