Photo of yourself:
Doctor Name* Andrew Chang MD Steven Davis MD John Einck MD Ryan Grover MD Jona Hattangadi-Gluth MD Ari Katerelos MD Iain MacEwan MD Loren Mell MD A.J. Mundt MD Brent Rose MD Carl Rossi MD Ajay Sandhu MD Parag Sanghvi MD Daniel Simpson MD James Urbanic MD Catheryn Yashar MD Other
Cancer Type* Breast Brain & Spine Colon Esophageal Throat Lymphoma Prostate Bladder Rectal Liver Tongue Sarcoma Pediatric Gastrointestinal Anal Head & Neck Nasal Testicular Lung Stomach Pancreatic & Bile Duct Mouth Thyroid Recurrent & Secondary
By executing below, I hereby agree as follows:
I irrevocably consent to use by California Proton Therapy Center, LLC ("CPTC") (doing business as "California Protons") and its successors, affiliates, licensees and assigns (the "CPTC Parties"), and grant to such CPTC Parties a fully-paid up, royalty-free, perpetual, exclusive license, throughout the world, to use my name, likeness (including video recording and/or still photography), image, voice community name and/or testimonial (collectively, the "Materials"), in whole or in part, including derivatives, in any media whatsoever, for CPTC health's promotional and/or commercial uses, as determined solely by CPTC health ("Promotional Use").
If I provide any photographs or other materials for use by CPTC Parties in connection with the Materials (the "Third-Party Materials"), I confirm that I have the full legal right, power and authority to grant such CPTC Parties the right to use the Third-Party Materials for the Promotional Use and that I have secured all necessary rights from any individuals appearing in such Third-Party Materials and any photographers or other contributors to such Third-Party Materials.
I hereby agree that any results of the Promotional Use, including, without limitation, all rights under copyrights, shall be the sole and exclusive property of CPTC health, with the full right to exploit and/or dispose of the same in any manner whatsoever.
I acknowledge and agree that I will not be entitled to any payment or other form of remuneration as a result of any use of Materials or Third-Party Materials.
I hereby waive any right to inspect and/or approve the Promotional Use and/or the finished product, media, video recording and/or printed matter that may use, incorporate, or exhibit the Materials and/or Third-Party Materials.
I hereby waive all rights to, and release, discharge and agree to hold harmless the CPTC Parties and their respective officers, directors, and employees from any and all claims or demands that I may have now or that I may have in the future regarding use of the Materials and/or Third-Party Materials by such CPTC Parties.
If this form is being filled out on behalf of a minor (e.g. by a parent or guardian), please indicate:
Description of legal authority** to sign on behalf of the minor:
**CPTC reserves the right to request valid documentation
Personal information such as street address, phone number and email address are for internal use only and will not be published.