Speaker Release Form

In consideration for my participation in the Summit and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I,

the undersigned, by electronic signature, hereby grant and release to the Forum for Healthcare Strategists (the “Forum”), its successors, assigns, and licensees (the “Forum and its agents”) the right to record my entire presentation, including my likeness, voice and verbal statements, on film, videotape, and audiotape (collectively, the “Tape”). I also grant the Forum the right to edit, distribute, and sell the Tape, alone or as part of a compilation, at its discretion without additional approval from me or compensation to me. Nothing in this Agreement constitutes an affirmative obligation on the part of the Forum to distribute the tape.

I further grant to the Forum and its agents the right to use the Tape, my name, likeness, voice, and biographical information and any other information about me in connection with the advertising, promotion, and public relations efforts relating to the Summit in any and all media, now known or hereafter created without any compensation to me.

I hereby grant to the Forum the right to reproduce any printed materials prepared by me for the Summit into a written handout or book without compensation to me.

I acknowledge the Forum’s right, as the owner of the Tape, to copyright the Tape in the Forum’s name and release the Forum and anyone authorized by it to use the Tape from any claims and liabilities I now have or may hereafter have by reason of the Forum’s use of the Tape and/or from my participating in the Summit.