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Speaker Release form for the 2019 Reverse Autoimmune Disease Summit
Thank You for participating in the Reverse Autoimmune Disease Summit. Please complete this form to access your interview booking link.
Participation in the summit will include electronic recording of the Guest/Speaker presentation and interview with Dr. Keesha Ewers. Guest/Speaker understands that for educational, promotional, and commercial applications, Dr. Keesha Ewers will make Speaker’s presentation/interview video recording available at no charge to summit registrants.
Guest/Speaker hereby grants to Dr. Keesha Ewers the right to use his or her name, voice, appearance, likeness, image, words, participation, and title or professional designation, in whole or part, in these recordings and/or compilations and in any correspondence, publicity, advertising, promotional, or other derivative materials based on them. Dr. Keesha Ewers has no obligation to make use of the rights granted herein.
Guest/Speaker hereby grants Dr. Keesha Ewers the unconditional and irrevocable right to reproduce the Recording in any format, and to distribute, sell, prepare derivative works, advertise, and publicize the Recordings without compensation to Guest/Speaker. Dr. Keesha Ewers may edit the Recordings at her discretion. Dr. Keesha Ewers shall own the worldwide rights, title, and interest, including copyright in, and to, the Guest/Speaker’s Recording. However, Guest/Speaker shall also retain the right to use his or her own Recording for any purpose.
Guest/Speaker, upon written request to Dr. Keesha Ewers, shall be provided with a copy of his or her Recording in electronic format.
Guest/Speaker agrees to send the minimum of 2 (two) solo emails to their whole database during the agreed-upon promotion period. The Guest/Speaker also agrees to make at least 1 (one) promotional post on all available social media outlets during the promotional period.
Please check the box below to confirm that you agree with point 4.
I Confirm That I Will Perform all promotional activities state in point 4.
Guest/Speaker is permitted to make a FREE offer during his or her presentation/interview including the provision of a URL or other traffic destination.
Guest/Speaker represents that he or she has the full right, power, and authority to grant this release and to perform all of the provisions thereof. Guest/Speaker acknowledges that in the event of a breach or alleged breach with respect to the terms and provisions hereof, that Dr. Keesha Ewers shall be entitled to such injunctive or equitable relief as Dr. Keesha Ewers may deem appropriate, in addition to such other rights or remedies Dr. Keesha Ewers may have at law.
Guest/Speaker agrees to indemnify and hold harmless Dr. Keesha Ewers from and against all claims, losses, expenses, and liabilities of every kind including reasonable attorney’s fees arising out of the Inaccuracy or breach of any provision of this Agreement. Guest/Speaker expressly releases Dr. Keesha Ewers from any and all claims arising out of the use of the material.
This release shall be governed in accordance within the state of Washington law, constitutes the entire agreement of the parties, and may be amended only in writing.
By completing and submitting this form, you confirm understanding and agreement to all terms and conditions stated above and confirm the accuracy of the information provide.
Your Contact Email Address
Your Primary Website URL
Upload Your Preferred Headshot (minimum 400x400 pixels)
Your Bio (approx 200 words)
Assistant/Point Of Contact Name
Assistant/POC Contact Number
Date Format: MM slash DD slash YYYY
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