Media Release Paragraph 1

I hereby grant to the Society for Imaging Informatics in Medicine (“SIIM”) and its authorized representatives and licensees:

(a) Permission to record in any media, including photography, film, video and/or audio, my voice, image, photograph, content and materials including any images of me and my likeness recorded as part of the below-noted event;

(b) Consent to use my media, including photography, film, video and/or audio, my voice, image, photograph, content and materials (including any images of me and my likeness recorded as part of the below-noted event in any form), as part of future publications, recruitment and other media and materials to promote SIIM or any of its programs or activities.

(c) To the extent I provide any endorsement or testimonial (“Testimonial”) to SIIM or any of its representatives, the unrestricted right and permission to use, reuse, publish, republish, produce, reproduce, edit or modify post-electronically, broadcast, present, sell, transfer and distribute in any manner the Testimonial;

(d) To the extent I submit any content of any nature, including, without limitation, documentation, films, photographs, videos, audio recordings, speeches, or other content (“Content”), the unrestricted right and permission to use, reuse, publish, republish, produce, reproduce, edit or modify post-electronically, broadcast, present, sell, transfer and distribute in any manner the Content.

Media Release Paragraph 2

I acknowledge that the rights granted herein may be exercised by SIIM without payment of fees, royalties, special credit or compensation. I acknowledge that my name may or may not be used in conjunction with such activities and materials and I relinquish any right that I may have to examine or approve such uses.

I hereby release, discharge and waive any damages, claims, actions or suits that I may have against SIIM and its authorized representatives and licensees, from any claims that may arise regarding the rights granted above and exercise of those rights, including, but not limited to any claims of defamation, invasion or rights to privacy, infringement or moral rights, right of publicity or personality or copyrights.

I understand that SIIM is not obligated to use my name, image, likeness or any of the Content or Testimonial identified above in any manner. I acknowledge that SIIM shall be the absolute owner of any materials (and all rights therein, including copyright) produced by SIIM pursuant to this media release.

Reviewed for Sensitivity

I attest that I have reviewed and edited my content to ensure that it does not contain content of a defamatory and/or discriminatory nature, including but not limited to age, sex, race, religion, gender, disabilities, etc.