*This form shall serve as a release for using my name, image, recordings, video likeness and/or photography in connection with educational, promotional, or advocacy purposes, and I, hereby grant the Community Liver Alliance and Pennsylvanians for Fair Health Coverage, its designated representatives and/or officers, directors, and employees (hereinafter called the “Releasees”) permission to use in perpetuity and royalty-free, my name, image, recordings, video likeness, written testimonial, and/ or photograph in connection with the educational, promotional, and advocacy materials of Pennsylvanians for Fair Health Coverage, in any manner and in any medium, as Pennsylvanians for Fair Health Coverage, in its sole discretion, shall deem appropriate or desirable. I hereby waive any right I may otherwise have to approve such use of my name, image, recordings, written testimonial, video likeness and/or photograph, and I release the Releasees from any claim or liability arising out of the reproduction of my name, image, recordings, written testimonial, video likeness and/or photograph, and/or likeness. The territory as to which the Release shall apply is worldwide and I acknowledge the receipt of good and valuable consideration for the rights granted herein. Nothing herein will constitute any obligation on Pennsylvanians for Fair Health Coverage to make any use of any of the rights set forth herein.