Authorization

Authorization and Release Agreement

By clicking the box above, I indicate my agreement with the terms of this Authorization and Release with Advocates for Medical Foods (Sponsored by Primus Pharmaceuticals), its directors, officers, employees, agents, volunteers and representatives. I have been informed and understand that the comments I make, or stories that I share, or photographs or video I might provide, including but not limited to my name, likeness, image, voice, appearance, performance and/or written words submitted to Advocates for Medical Foods (hereinafter the “Production”), might be included by Advocates for Medical Foods on its internet website, including but not limited to Advocates for Medical Foods social media site(s) and/or other public web site(s), to be determined in the sole discretion of Advocates for Medical Foods.

To this end, I understand that I am providing information about my personal experience with medical foods that identifies me and that might describe my past or present mental or physical condition.

I acknowledge that I grant Advocates for Medical Foods the right to use and disclose this information to the general public on the Advocates for Medical Foods website in order to serve the purpose of increasing public awareness of medical foods. I also understand that the information I am providing Advocates for Medical Foods can easily and without permission be copied and reused by Advocates for Medical Foods website visitors who copy the Production from the Advocates for Medical Foods website.

I grant Advocates for Medical Foods the right to use, publish, display, reproduce, transmit and distribute my name, likeness, image, voice, appearance, performance and/or written words submitted to Advocates for Medical Foods as embodied in the Production or any derivation, in any medium or format whatsoever, for any purpose, whether recorded on or transferred to print, videotape, film, slides, photographs, audio tapes, web site, internet, electronic media or other media, now known or later developed. This grant includes without limitation the right to edit, mix or duplicate and to use or re-use the Production in whole or part as Advocates for Medical Foods may elect. Advocates for Medical Foods shall have complete ownership of the Production in which I appear, and I hereby assign and convey to Advocates for Medical Foods all rights, title and interest and copyright ownership in and to the Production, and I acknowledge that I have no interest or ownership in the Production or its copyright.

I also grant Advocates for Medical Foods the right to broadcast, exhibit, publish, and otherwise distribute the Production either in whole or in part, and either alone or with other products, for commercial or non-commercial use or any other purpose Advocates for Medical Foods in its sole discretion may determine. The rights granted Advocates for Medical Foods herein are, unless I revoke them as described below, perpetual and worldwide.

I confirm that I have the right to enter into this Agreement, that I am not restricted by any other commitment. By sharing the Production and/or other information with Advocates for Medical Foods, you agree that Advocates for Medical Foods owes you no compensation, consideration, acknowledgement, duty or protection of your work and you promise that the Production does not violate anyone’s rights.

I EXPRESSLY RELEASE AND INDEMNIFY ADVOCATES FOR MEDICAL FOODS FROM ANY AND ALL CLAIMS, DEMANDS, CAUSES OF ACTION, LIABILITY, OR INJURY, KNOWN AND UNKNOWN, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE ABOVE GRANTED USES, CONVEYANCES, PERMISSIONS AND/OR REPRESENTATIONS.

This Authorization will remain in full effect until such time as Advocates for Medical Foods decides it will no longer use any of the information I have provided to it or until I revoke this Authorization, whichever occurs first.

I understand that I may revoke this Authorization at any time except to the extent that Advocates for Medical Foods has relied on it, but I agree that I may not revoke my release or indemnity of Advocates for Medical Foods. To revoke this Authorization I understand that a written revocation must be provided to Advocates for Medical Foods by mailing it to:

Marketing Manager, Advocates for Medical Foods c/o Primus Pharmaceuticals, 7373 N. Scottsdale Road, Suite B-200, Scottsdale, AZ 85253.

These terms are a legal contract that will bind both of us as soon as agree to the terms and conditions.

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