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—Please choose an option—Amherst - Amherst ManorAmherst - 1907 Assisted Living At Central SchoolAvon Lake - Towne Center Community CampusLorain - Anchor LodgeLorain - Autumn AegisMassillon - Rose LaneOlmsted Falls - Village Of The FallsTallmadge - Heather KnollTwinsburg - Grande VillageWellington - Elms Retirement VillageWooster - Smithville WesternBluffton / Okatie - Sprenger Healthcare BlufftonPort Royal - Sprenger Healthcare Port RoyalCorporateNo Specific Location

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I hereby agree (a) to be interviewed, (b) to the recording of this interview in any form and in any media, and (c) to provide information and other materials, including my personal experiences, remarks, incidents, dialogues, actions, and recollections, as well as any photographs and documents (collectively, the “Testimonial Materials”). I hereby grant to Sprenger Healthcare and its affiliates, licensees, successors, and assigns (collectively, “SHCS”) throughout the world and in perpetuity: (A) the right to quote, paraphrase, reproduce, publish, distribute, transmit, display, license, or otherwise use all or any portion of the Testimonial Materials for use (i) on the SHCS website, (ii) in advertising and related promotion of SHCS, and (iii) for any and all other purposes whatsover in all forms and in all media; (B) the right to use my name, image, and biographical data in connection with any use of the Testimonial Materials; and (C) the right to use digital manipulation or distortion in connection with the Testimonia Materials. I hereby waive any right I may have to inspect or approve the use of my name, image, biographical data or Testimonial Materials and acknowledge that I have no copyright or other rights in any media created by SHCS using the Testimonial Materials. I hereby release and discharge SHCS from any and all claims, demands, or causes of action that I may have against them regarding any use of the Testimonial Materials or any media created by SHCS, including any claims based on the right to privacy, the right to publicity, copyright, libel, defamation, or any other right.

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