Tell Your Well Story

WELL MEMBER TESTIMONIAL 

CONSENT AND RELEASE FORM 

 

I understand that Well Dot, Inc. (“Company” or “Well”) would like me to submit a recorded member testimonial video regarding my experience with the Company’s health and wellness service (the “Member Testimonial”). My submission will include my name, the email account associated with my Well account, and a self-recorded video describing my experience with the Well app. (the “Submission”). The Submission will be used for education, development of promotional materials, and other business purposes. 

I hereby agree to participate in the Member Testimonial and give permission to Company for the use of the Submission. I agree that in the Member Testimonial, I may be identified by first name and office location of my employer.  

I hereby grant to Company and its designees the unrestricted, perpetual, worldwide right to reproduce, copy,  modify, create derivative works of and otherwise use, display, distribute, exhibit, transmit and broadcast the  the Submission (including my likeness and image), or any part thereof, in any media, means or embodiment, now known or hereafter to become known, (collectively, the “Works”), without additional payment to me of any kind. I hereby waive any right of inspection or approval of my appearance in the Works. I understand and agree that the Submission, including all video and audio and derivative works produced from the same, shall become and remain the sole property of Well, and I shall have no right or title to such items. 

I hereby release Company and its agents, designees, affiliates, and representatives, and any facility in which the  Submission is obtained, and each of their respective employees, officers, directors, shareholders, agents and representatives from ANY AND ALL LIABILITY relating to the Member Testimonial, the subject matter thereof and the Works, and agree that I shall neither seek nor bring any proceeding against any such party for any claim or cause of action which is directly or indirectly based upon or related to the Submission, the Works or my participation in the Member Testimonial. 

I acknowledge that the information concerning my participation in the Member Testimonial, is strictly confidential and I shall not use or disclose to third parties any information, ideas, concepts, business, or issues that are disclosed, provided, discussed or may result from  my participation in the collaboration. 

I understand that Company and all marketing partners associated with Company will comply with HIPAA  guidelines with regard to my personal health information. By signing below, I hereby represent that (i) I am over the age of eighteen (18) years, (ii) I have read (or have had read to me) and understand this Consent and Release Form, (iii) I have full authority and right to execute this Consent and Release Form and do so voluntarily, (iv) the terms of this Consent and Release Form will not conflict with any other agreement or instrument to which I am a party or by which I am bound, (v) this Consent and Release Form will be governed by the laws of the State of Delaware, without regard to its conflicts of laws provisions and (vi) I am an independent contractor and not entitled to any employee benefits. 

Signature:____________________ 

Printed Name:____________________________ 

Date:___________________________________