The Institute for Natural Medicine, a Washington state 501(c)(3) with offices located at 4500 9th Ave NE, Ste 300, Seattle, WA 98105 (the "Company") desires to interview and record such interview, and use and publicize the name, likeness, and other personal characteristics and private information of, the individual named below ("I" or "me") for [SPECIFIC PURPOSE] (the "Work")[, advertising and promotion of the Work][, and advertising, promotion, and other commercial and business purposes]. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

For [[the intangible value I will gain by participating in the interview]/[RECITAL OF OTHER NOMINAL CONSIDERATION]] [and other] good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I irrevocably grant Company permission to interview me (the "Interview”), to film, record, and photograph the Interview (the "Recording”), and to use the Interview, the Recording, and my name, likeness, and other personal characteristics and information in connection with the Work, according to the terms and conditions set forth in this Interview Release ("Release"). *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

I hereby irrevocably permit, authorize, and license Company and its affiliates, successors, licensees, agents, and assigns ("Authorized Persons") to digitize, modify, alter, edit, adapt, create derivative works, display, publicly perform, exhibit, transmit, broadcast, reproduce, exploit, sell, rent, license, otherwise use and distribute, and permit others to use and distribute the Interview, the Recording and the Work, including my name, image, likeness, appearance, and voice as they appear in the Interview, Recording, and/or Work, on a perpetual basis throughout the world, in any medium or format whatsoever whether now existing or hereafter created[, including without limitation internet streaming and downloading, websites, other digital transmission methods, mobile applications, television broadcast, cablecast, satellite, home video, video on demand, pay television, pay-per-view, radio, and print publications], on any platform whatsoever whether now existing or hereafter created[, including without limitation televisions, computers, and mobile devices], and in connection with any and all ancillary products[, including without limitation merchandise, books, and software applications], without further consent from or any royalty, payment, or other compensation to me [except as otherwise expressly provided in this Release]. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

Further, I hereby irrevocably permit, authorize, and license Company and the Authorized Persons to use and distribute, and permit others to use and distribute, my name, likeness, appearance, voice, [professional and personal biographical information,] [signature,] [other personal characteristics,] [and] [private information,] and all materials created by or on behalf of Company that incorporate any of the foregoing ("Materials"), in connection with the Work and advertising and promotion of the Work [and advertising, publicity, and promotion of the Company and its affiliates and their businesses, products, and services,] on a perpetual basis throughout the world, in any medium or format whatsoever whether now existing or hereafter created[, including without limitation internet streaming and downloading, websites, other digital transmission methods, mobile applications, television broadcast, cablecast, satellite, home video, video on demand, pay television, pay-per-view, radio, and print publications], on any platform whatsoever whether now existing or hereafter created[, including without limitation televisions, computers, and mobile devices, and display, point-of-sale, direct mail, and other advertising and promotional platforms and methods], without further consent from or any royalty, payment, or other compensation to me [except as otherwise expressly provided in this Release]. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

I agree that Company is and will be the sole and exclusive owner of all right, title, and interest in and to the Work, the Interview, the Recording, and the Materials, including without limitation all copyrights and other intellectual property rights therein, in perpetuity throughout the universe. In furtherance of the foregoing, I agree that the results and proceeds of my services in connection with the Interview and Recording are works made for hire for Company as defined in Section 101 of the Copyright Act of 1976. To the extent the Interview, the Recording, the Materials, or any part of either does not qualify as, or otherwise fails to be, a work made for hire, I shall, and hereby do, (a) assign, transfer, and otherwise convey to Company, irrevocably and in perpetuity, throughout the universe, all of my right, title, and interest, if any, in and to the Interview, the Recording, and the Materials, including without limitation all copyright and other intellectual property rights (which shall include, without limitation, all registration, renewal, and reversion rights) and the right to register and sue to enforce such copyrights against infringers; and (b) irrevocably waive any and all claims I may now or hereafter have in any jurisdiction to so-called "moral rights" or rights of droit moral in the Interview, the Recording, and the Materials. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

Company has no obligation to create or use the Work, the Interview, the Recording, or any Materials, or to exercise any rights given by this Release. I acknowledge and agree that I have no right to review or approve the Work, the Interview, the Recording, or the Materials before they are used by the Company or at any other time, and that the Company has no liability to me for any editing or alteration of the Work, the Interview, the Recording, or the Materials, or for any distortion or other effects resulting from the Company's editing, alteration, or use of the Work, the Interview, the Recording, or the Materials, or Company's presentation of me. Any acknowledgment or credit accorded to me in connection with the Work or the Materials, if any, shall be determined by Company in Company's sole discretion. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

To the fullest extent permitted by applicable law, I 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 known or hereafter known in any jurisdiction throughout the world (collectively, "Claims"), arising directly or indirectly from the Authorized Persons' exercise of their rights under this Release and the use and exploitation of the Work, the Interview, the Recording, and/or the Materials, and whether resulting in whole or in part by the negligence of Company or any other person, 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. I understand that Company is relying on this Release and will incur significant expense in reliance on this Release, and I agree that this Release cannot be terminated, rescinded, or modified. I waive my right to injunctive and other equitable relief in the event of a dispute with the Company. I will not have the right to enjoin or interfere with the production, distribution, exploitation, advertising, or promotion of the Interview, the Recording, the Materials, or the Work. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of 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 Release and grant the rights hereunder. I further represent and warrant to Company that I will provide only true and correct information in the Interview and that my participation in the Interview, and the Authorized Persons' use of the Interview, the Recording, and the Materials, and the rights and license granted hereunder, do not, and will not, violate any right of, or conflict with, or violate any contract with or commitment made to, any person or entity, and that no consent or authorization from any third party is required. [I agree to [defend,] indemnify[,] and hold harmless the Authorized Persons from and against all Claims by third parties resulting from my breach of this Release or any of the foregoing representations and warranties.] *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

Company has no obligation to create or use the Work, the Interview, the Recording, or any Materials, or to exercise any rights given by this Release. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

This Release is my complete understanding regarding the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, regarding such subject matter. If any term or provision of this Release is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. Company may assign this Release and its rights hereunder, in whole or in part, to any party. This Release shall be binding on and shall inure to the benefit of Company and me and our respective successors and assigns. All matters arising out of or relating to this Release shall be governed by and construed in accordance with the internal laws of the State of Washington state without giving effect to any choice or conflict of law provision or rule (whether of the State of Washington state or any other jurisdiction). Any claim or cause of action arising under this Release may be brought only in the federal and state courts located in Washington state, and I hereby irrevocably consent to the exclusive jurisdiction of such courts. [I agree that I will not disclose any information about the Interview, the Recording, or the Work without Company's prior written consent.] *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

In order to ensure the Company's ability to reach the public with accurate, appropriate, and complete information, the Company seeks to work with individuals and organizations that will help us maintain a highly credible and authoritative identity. As such, all the Company's media partners (including contributors, interviewees, experts, hosts, and other personalities) are subject to reputational and qualification review. This process may include a review of web and personal or professional social media presence for all media partners, as well as a review of previous publication, internal professional reputation, censures, criminal history, apparent conflicts of interest, and/or other details. Decisions made as a result of media partner review are at the sole discretion of the Company. Said decisions and the events that inform them may occur before, during, or after publication and may result in cancellation, adjustment, or removal of the respective content. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

THIS RELEASE PROVIDES THE COMPANY WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING THE COMPANY TO PUBLICIZE AND COMMERCIALLY EXPLOIT YOUR NAME, LIKENESS, AND OTHER PERSONAL CHARACTERISTICS AND PRIVATE INFORMATION AS SET OUT ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE COMPANY. *

By checking this box I acknowledge I have read, reviewed, and agree to the respective term(s) of this agreement.

Name of Interviewee *

By typing my full name below, I give consent for the name I enter to serve as both my printed and signed name for this Release.

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Name of Parent or Legal Guardian if above named is a minor.

First Name

Last Name

I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below, I hereby do consent in all respects to the terms and conditions of this Release.[

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