VIDEO AUTHORIZATION RELEASE

Conditions

I hereby grant the EMBRY WOMEN'S HEALTH LLC, its directors, officers, employees, agents, and designers (collectively “EWH”) non-revocable permission to capture my image and likeness in videotapes, motion pictures, recordings, or any other media (collectively “Images”).

I acknowledge that EWH will own such Images and further grant the EWH permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to EWH business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the EWH prior to its use. I forever release and hold the EWH harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below.

This release is binding on me and my heirs, assignees and personal representatives.