I am submitting a video, photographs, stories or other content (referred to as “Material”) which may be used by Access to Medical Imaging Coalition (“AMIC”) as follows:

• On the Internet – on AMIC’s website and the websites of AMIC’s affiliates and on third party social media sites such as YouTube
• In print – in newspapers, magazines, flyers and in other materials available publicly
• In presentations – to the media, other patients, medical professionals and other interested parties
• In other publicly distributed or available sources

I understand that AMIC and/or its agents may edit the Materials and use all or part of the Materials for any of the uses described above.

By signing below, I give my permission to AMIC and its partners and agents to use the Materials, including my name, likeness, personal story and voice without further compensation. It is my understanding that my signature below releases Access to Medical Imaging Coalition from any financial or legal responsibility for the use of the Materials. I confirm to AMIC that I own the Materials and have the right to grant AMIC the rights I am granting to it in this Release Form.