PHOTO/VIDEO RELEASE FORM

Thank you for helping us in our mission to save lives.  It is important to create greater awareness of choking statistics and therefore it is important for us to be able to use stories like yours to get that message out there.  Please consider allowing LifeVac to use your images, videos, and story to continue in our life saving mission.

I hereby grant permission to LifeVac, LLC. to use photographs and/or videos of me in publications, news releases, online, and in other communications related to the mission of LifeVac, LLC.

Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.