For valuable consideration received, I hereby grant the Society for Vascular Surgery and its agents, volunteers, employees, successors, assigns, and representatives (collectively, “SVS") the irrevocable and unrestricted right (but not obligation) to use, publish and copyright the photo, video, statement, name and/or voice, digital images, scans and other visual recordings submitted along with this Agreement (collectively, the “Image”) in SVS marketing, promotional, fundraising, communication, educational and other materials (including, but not limited to its websites, videos, newsletters, advertisements, brochures, fundraising materials and any and all other medium) (collectively, the “Materials”).

In addition, I hereby agree as follows:

I understand that the Image may be created, published, distributed, reproduced, copyrighted, and otherwise used for the purposes of disseminating information about and promoting SVS and its services, products and programs and may appear in SVS Materials.

I hereby represent that, to the best of my knowledge (i) the Image does not violate any copyright, proprietary rights or personal rights of others; (ii) I have obtained all necessary permissions to reproduce or use any materials for which I am not the author or copyright holder; (iii) the Image does not identify, by name or otherwise, suggest the identity of, or present a recognizable likeness of any individual or individuals, or, if it does, I have obtained all necessary written consents from such individual(s) for the further use, distribution and publication of the Image; and (iv) I am authorized to make these representations.

I understand that I may be named in the Materials accompanying the Image.

I waive any right to inspect or approve the Image or any Materials in which my Image appears.

I release and discharge SVS from any claim that I may have relating to the creation, publication, distribution, sale, reproduction, copyright, or other use of the Image, including without limitation, any claim for payment in connection with such use.

I enter into this Agreement voluntarily, with no requirement to do so, and I understand that SVS will owe me no compensation for the use of the Image.

By checking the box below, I acknowledge that I have read and understand this Agreement and agree to its terms: