Appearance Release

Effective date: October 2023

In exchange for good and valuable consideration, the receipt and sufficiency of with I hereby acknowledge, I authorize Imagine Pediatrics, LLC and its affiliates (collectively, “Imagine Pediatrics”) to use, disclose and publicize the following information about the patient listed above (“Patient”) and the parent/guardian undersigned below (“I”, “me”, “you”, “my”) for any media, marketing, promotional, educational, fundraising, publication, and research activity purposes as set forth in this Appearance Release: full name, voice, likeness, conversations, sounds, biographical information, personal testimonials, date(s) of services, and any and all health or other identifiable information provided by me or Patient in testimonials or reviews, which may include, but not be limited to, information relating to the diagnosis, treatment and health care services provided to Patient by Imagine Pediatrics (“Appearance Materials”). Appearance Materials may also include information provided in photography and audio/video recordings, and other marketing activity involving Imagine Pediatrics in which the Patient and I voluntarily participate.

I grant Imagine Pediatrics a royalty-free, fully paid-up, irrevocable right and license to use, re-use, publish, republish, distribute, modify, adapt, translate, combine with other works, create derivative works from, exploit, license, sublicense and display Appearance Materials, in whole or in part, worldwide, at any time in perpetuity, in all media now known or hereafter devised for the commercial, promotional and publicity purposes of Imagine Pediatrics, including without limitation, the general public in print, broadcast, electronic, and social media. For example, Imagine Pediatrics may use and disclose the information to the general public through print media, electronic media (including email), on the radio, TV, websites, blogs and other social media platforms, including, but not limited to, Facebook, LinkedIn, X (formerly Twitter), Instagram, and YouTube, and may disclose the information to third parties that assist Imagine Pediatrics in creating such content. I hereby waive any right to inspect or approve the Appearance Materials, or any printed, electronic or digital matter that may be used in connection therewith. I further understand that My Likeness may be subject to reasonable modifications or editing by Imagine Pediatrics.

I understand I will not be compensated for my or the Patient’s appearance in the Appearance Materials. I understand that use and disclosure of this information may result in direct or indirect remuneration to Imagine Pediatrics.

I hereby hold harmless and release Imagine Pediatrics from all claims, liability or damages of any nature, including, without limitation, claims for breach or invasion of any personal or property right which I or Patient may have, or which my or their heirs, executors, administrators and assigns hereafter may have, including without limitation, claims based upon invasion of privacy, libel, defamation, commercial appropriation, use of likeness, infringement of copyright, right of publicity, or for any matter or cause of action whatsoever arising out of the Appearance Materials and their use as provided herein.

I represent and warrant that: (i) I have read this Appearance Release in its entirety and understand its terms, (ii) I intend for this Appearance Release to be binding on me, my heirs, legal representatives, assigns,executors, administrators to the fullest extent permitted by law, and (iii) this license does not in any conflictwith any existing commitment on my part, and any Appearance Materials are true, to the best of my knowledge,and the Appearance Materials will not violate or infringe upon the rights of Imagine Pediatrics or any third party.

This Appearance Release shall be interpreted and enforced in accordance with the laws of the State of Delaware except for its conflicts of laws principles, and I hereby irrevocably consent to the exclusive jurisdiction of Delaware courts over disputes relating to this Appearance Release. I shall not raise, and hereby waive, any defenses based upon improper venue, inconvenience of the forum, lack of personal jurisdiction, or the sufficiency of service of process. Termination of this Appearance Release, for any reason, shall not affect Imagine Pediatrics rights in the Appearance Materials. Imagine Pediatrics may assign its rights in this Appearance Release, in whole or in part, to any individual or entity, without restriction. This Appearance Release represents the entire understanding and supersedes all prior understandings between the parties relating to the subject matter herein.