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**Please note that by submitting your story and clicking “Submit” you agree to the following:

I hereby grant to Prescription Process Advocacy Network and its affiliates and each of their respective officers, directors, employees, agents and legal representatives, and those acting with authority or permission from any of them, the absolute, irrevocable and unrestricted right to use, publish, display, edit, modify and distribute materials bearing, in whole or in part, my name, voice, image, likeness, biographical information or any other identifiable representation or personal indicia of myself (collectively, “Covered Information”) for noncommercial purposes only and in connection with this campaign and/or  work in prescription process reform. These materials may appear in any form, style, color or medium whatsoever now existing or developed in the future (including, without limitation, photographs, videotapes, films, sound recordings, software, drawings, print publications, broadcast, Internet and electronic media) and for the purposes described herein. I hereby fully and forever release, discharge and hold harmless Prescription Process Advocacy Network from all liability or damages relating to the use of this Covered Information.  I agree not to sue Prescription Process Advocacy Network for all claims, demands, damages, rights of action, or causes of action relating to the use of this Covered Information, present or future, whether known or unknown, anticipated or unanticipated, including without limitation any claims for violation of right of publicity, libel or invasion of privacy. I hereby waive my rights, if any, to be compensated for use of any Covered Information. I also waive the right to inspect or approve the finished materials or any part or element thereof that incorporates, in whole or in part, any Covered Information. I have agreed to the above in consideration of the opportunity given to me by Prescription Process Advocacy Network to appear in these materials.

I also grant Prescription Process Advocacy Network rights to the story and waive all claims against Prescription Process Advocacy Network and its affiliates relating to the use of such Covered Information.  I represent that the Covered Information story is my own and that to the best of my knowledge, the use of my story will not infringe on anyone else’s proprietary right.