Personal Release

I, _______________________, hereby irrevocably grant to Dysautonomia Information Network, your successors and assignees, the right to record my likeness and/or voice on film, to edit such film at your discretion, to incorporate the same into a project tentatively called "Dysautonomia Documentary" and to use or authorize the use of such film or any portion thereof in any manner or media at any time or times throughout the world in perpetuity and to use my name, likeness, voice and biographical and other information concerning me in connection therewith, including promotions in all media.

I hereby release you and anyone using said film or other material from any and all claims, damages, liabilities, costs, and expenses which I now have or may hereafter have by reason of any use thereof.

I understand that the provisions of this release are legally binding.