Photo and Publication Consent and Release Form

For good and valuable consideration herein acknowledged as received, I hereby grant Betterlives LLC(the “Company”) permission to use my likeness in a photograph, other digital reproduction and written publication in any and all of its brochures, newsletters, articles, website, and on the Company’s internal Document Management and Consumer Database referred to as the Back Office Web (“BOW”)

I understand and agree that these materials will become the property of the Company and will not be returned. I hereby irrevocably authorize the Company to edit, alter, copy, exhibit, publish or distribute this photo and/or publication for purposes of publicizing its programs, or for any other lawful purpose.

I further consent to the recording of my statements and grant to the Company the right to copy, reproduce, and use all or a portion of the statements (the “interview”) at its’ discretion.

Check one for each section:

I understand and acknowledge that any photos taken will be posted internally on the BOW for purposes of identifying me to company employees, and/or appropriate authorities and regulatory agencies in the the event of an incident that requires legal and/or regulatory notification.

Please select an option.

Yes

I further understand, acknowledge and permit photos to be taken for the purpose of participating in Company sponsored contests and/or events that may be posted on the BOW and/or the Company’s public website, to be determined at the Company’s sole discretion.

I grant the right to use my image and my name in connection with all uses of the interview and publications, and waive the right to inspect or approve the finished product, including use of my interview, in written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or interview if applicable.

Please select an option.

Yes

I hereby hold harmless and release and forever discharge the Company, its affiliate entities, officers, directions, employees, agents and representatives from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of the Consent and Release.

I am 18 years of age and am competent to provide this Consent and Release in my own name. I have read this Release before signing below and I fully understand the contents, meaning and impact of this Release.

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Date

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If the person signing is under age 18 or not capable of individually providing consent, there must be consent by a parent, guardian or legally authorized representative as follows: I hereby certify that I am the parent, guardian, or legally authorized representative of the individual named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.