MARKETING WAIVER AND RELEASE

MARKETING WAIVER AND RELEASE (AMT TESTIMONIAL SUBMISSION)
I (or “my”), the individual named at the top of the AMT Testimonial Submission Form, on my own behalf, or on the behalf of an individual that I have the full right, power, and authority to act on behalf of whether as a parent, legal guardian, power of attorney holder, or otherwise (the “Represented Person”; “I” and “Represented Person” are collectively referred to as “Authorizing Parties”), desire hereunder to allow Applied Medical Technology, Inc., an Ohio corporation located at 8006 Katherine Boulevard, Brecksville, Ohio 44141 (the “Company”) to (i) use the image, name, likeness, and/or other personal characteristics and private information of the Authorizing Parties and/or (ii) obtain the Authorizing Parties’ physical and actual involvement in, or production of, the Materials (defined below) for advertising, marketing, promotion, and/or other commercial and business purposes. The Authorizing Parties hereby acknowledge and provide Company with permission for such use, involvement, and publicity for such purposes, according to the terms and conditions set forth in this Marketing Waiver and Release (the “Agreement’).

The Authorizing Parties hereby permit, authorize, grant, and license Company and its affiliates, successors, and assigns, and their respective advertising agencies, and the employees, officers, directors, and agents of each (“Authorized Persons”), the rights to, including but not limited to, display, exhibit, transmit, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works from, and otherwise use the Authorizing Parties’ name, image, photo, likeness, appearance, voice, and other personal characteristics and all materials drafted, generated, or created by, or on behalf of the Authorizing Parties or Company that incorporate any of the foregoing (“Materials”) in perpetuity throughout the universe in any medium or format whatsoever now existing or hereafter created, including, but not limited to, print publications, testimonials, virtual media, motion pictures, advertising and educational materials, and internet and other digital transmission or delivery methods on any platform and for the purpose of advertising, marketing, public relations, publicity, packaging, education, and promotion of Company and its affiliates and their businesses, products, and services, without compensation. For the avoidance of doubt, if the Authorizing Parties are an employee, officer, or director of Company, they will not receive any compensation for this Agreement in addition to the compensation they receive for their employment with Company. The Authorizing Parties fully understand that they have the right to revoke this authorization or future use of the Materials by providing written notice to Legal@AppliedMedical.net. However, the Authorizing Parties understand that Materials may have been disclosed externally to third parties (via Company’s website or otherwise) and Company cannot perform any revocation on certain Materials.

Company shall be the exclusive owner of all rights, including copyright, in the Materials, including those Materials the Authorizing Parties personally draft, generate or create upon submission of the Materials to Company. The Authorizing Parties hereby irrevocably transfer, assign, and otherwise convey to Company their entire right, title, and interest, if any, in and to the Materials and all copyrights and other intellectual property rights in the Materials arising in any jurisdiction throughout the universe in perpetuity, including all registration, renewal, and reversion rights, and the right to sue to enforce such copyrights against infringers. As it relates to Materials drafted, generated, or created by Company, the Authorizing Parties acknowledge and agree that they may not have a right to review or approve Materials before they are used by Company, and that Company has no liability to them for any editing or alteration of the Materials. Company has no obligation to create or use the Materials or to exercise any rights given by this Agreement.

To the fullest extent permitted by applicable law, the Authorizing Parties hereby irrevocably waive all legal and equitable rights relating to all liabilities, claims, demands, actions, suits, damages, and expenses, including but not limited to, claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy, violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory, now or hereafter known in any jurisdiction throughout the world (collectively, “Claims”), arising directly or indirectly from Company’s and/or the Authorized Persons’ exercise of their rights under this Agreement or the production, exhibition, exploitation, advertising, promotion, or other use of the Materials, as well as the placement of any of Company’s products in or on the Authorizing Parties’ physical person, and whether resulting in whole or in part from the negligence of Company or any other person, and the Authorizing Parties hereby covenant not to make or bring any such Claim against any Authorized Persons and forever release and discharge the Authorized Persons from liability under such Claims.

The Authorizing Parties agree to indemnify, hold harmless, and defend Company, its officers, directors, employees, agents, affiliates, successors, and permitted assigns against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys’ fees, that are incurred by Company, arising out of or related to any third-party claim resulting from the Authorizing Parties’: (i) breach of non-fulfillment of any provision of this Agreement; (ii) negligent or grossly negligent act or omission in connection with this Agreement; (iii) reckless or willful misconduct; (iv) act or omissions that lead to or cause damage to the property of a third-party; or (v) failure to comply with any applicable federal, state, or local laws, regulations, or codes in performance of their obligations under this Agreement.

I represent and warrant to Company that I am at least eighteen (18) years of age and I have full right, power, and authority to enter into this Agreement and grant the rights granted hereunder, whether on my behalf or on behalf of the Represented Person. I further represent and warrant to Company that I will provide only true and correct statements and other information in connection with this Agreement, and the Authorized Persons’ use of the Materials and the rights and license granted hereunder do not, and will not, violate any right (including without limitation copyright, trademark, trade secret, right to privacy, or right of publicity) of, or conflict with or violate any contract with or commitment made to, any person or entity, and that no consent or authorization from, or any payment to, any third party is required in connection herewith.

This Agreement, in conjunction with any other terms, conditions, consent, authorization and submission under the AMT Testimonial Submission Form, constitute the sole and entire agreement of the parties with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. We, the Authorizing Parties, have not relied on any statement, representation, warranty, or agreement of Company or of any other person on Company’s behalf, including any representations, warranties, or agreements arising from statute or otherwise in law, except for the representations, warranties, or agreements expressly contained in this Agreement. If any term or provision of this Agreement is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability will not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction. Company may assign this Agreement and its rights hereunder, in whole or in part, to any party. This Agreement is binding on and inures to my benefit and the benefit of Company and our respective heirs, executors, administrators, legal representatives, successors, and permitted assigns. All matters arising out of or relating to this Agreement will be governed by and construed in accordance with the internal laws of the State of Ohio without giving effect to any choice or conflict of law provision or rule (whether of the State of Ohio or any other jurisdiction). Any claim or cause of action arising under this Agreement may be brought only in the federal and state courts located in Cuyahoga County, Ohio and the Authorizing Parties hereby irrevocably consent to the exclusive jurisdiction of such courts.

THIS AGREEMENT PROVIDES COMPANY WITH THE AUTHORIZING PARTIES’ CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING COMPANY TO PUBLICIZE AND COMMERCIALLY EXPLOIT THEIR NAME, IMAGE, PHOTO, LIKENESS, AND OTHER PERSONAL CHARACTERISTICS, AS WELL AS OBTAIN THEIR INVOLVEMENT IN THE MATERIALS, AS SET OUT ABOVE. THE AUTHORIZING PARTIES UNDERSTAND THAT THEIR TREATMENT, PAYMENT, ENROLLMENT, OR ELIGIBILITY FOR BENEFITS WILL NOT BE CONDITIONED ON WHETHER THEY SIGN THIS AGREEMENT. THE AUTHORIZING PARTIES UNDERSTAND THEY HAVE THE RIGHT TO REFUSE TO ENTER THIS AGREEMENT AND ENTER THIS AGREEMENT VOLUNTARILY WITHOUT COERCION FROM AMT.

I ACKNOWLEDGE, AGREE AND UNDERSTAND THAT BY SELECTING THE CHECK BOX ON THE FOLLOWING WEBSITE, HTTPS://WWW.APPLIEDMEDICAL.NET/RESOURCE/SHARE-YOUR-SUCCESS-STORY/, I AM FULLY ACKNOWLEDGING AND AGREEING TO THE TERMS AND CONDITIONS OF THIS AGREEMENT AND HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I (EITHER MY OWN LEGAL RIGHTS OR THE LEGAL RIGHTS OF THE REPRESENTED PERSON) GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE COMPANY. FURTHERMORE, WE, I ACKNOWLEDGE, AGREE AND UNDERSTAND THAT BY CHECKING THE BOX I AM REPRESENTING TO AMT THAT I AM EIGHTEEN (18) YEARS OF AGE AND HAVE THE FULL RIGHT, POWER, AND AUTHORITY TO ENTER INTO THIS AGREEMENT ON MY OWN BEHALF, OR ON BEHALF OF THE REPRESENTED PARTY.

HIPAA Authorization Form

The Health Insurance Portability and Accountability Act (“HIPAA”) requires an individual to specifically consent to and authorize the use of protected health information before the information is used outside of providing healthcare to an individual.
By checking the box on the AMT Testimonial Form, I, the individual named at the top of the AMT Testimonial Submission Form, on my own behalf, or on the behalf of a represented person (minor, incapacitated, etc.) that I have the full right, power, and authority to act on behalf of whether as a parent, legal guardian, power of attorney holder, or otherwise (the “Represented Person”), authorize Applied Medical Technology, Inc. (“AMT”), its employees, agents, and affiliates as the class of persons to use my, or the Represented Person’s, protected health information, which includes, and is not limited to, my first and last name, my likeness, including photos and videos, as well as any documents, images, scans, or other information directly related to my diagnosis, prognosis, treatment, or medical condition (the “Materials”), for the purpose of the development of AMT education, training, advertising, public relations, promotion, publicity, publication, packaging, and marketing. Furthermore, I understand that Materials used or disclosed pursuant to this authorization may be re-disclosed by AMT and its confidentiality may no longer be protected by federal or state law.
I understand that this authorization shall expire twenty (20) years from the date of submission of the AMT Testimonial Form for any new use of the authorized information. I understand that I have the right to revoke this authorization (whether completely or in part) and future use of the Materials at any time by providing written notice to AMT at Legal@AppliedMedical.net. However, I understand that once AMT uses the Materials, I cannot revoke authorization for that use.
Additionally, I acknowledge that my, or the Represented Person’s, treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form. AMT owes me no financial benefit from signing below. I understand that I have the right to refuse to sign this authorization. I have not been coerced by any party, whether involved or involved with this form, and I provide this authorization as a voluntary contribution and hereby release and discharge AMT from all claims to copyright ownership, payment, or other rights that I may have with respect to the Materials as indicated above.
I certify that I have read this document in its entirety and fully understand all terms and conditions. (If signing on behalf of a Represented Person, I certify that I am the parent, guardian, or the individual with the authorized power of attorney to sign on behalf of the Represented Person).