LIFE SURGE LLC
Testimonial Consent

I, the undersigned, of legal age, hereby grant, irrevocably and perpetually to Life Surge LLC and
their parent, subsidiaries, affiliates, successors and assigns thereof (hereinafter referred to as
“Company”), claiming under or through same, the following:

The right to photograph and record my name, voice, appearance, likeness and image along with any material furnished by me, and to publish, exhibit, distribute and use my name, voice, appearance, likeness and image along with any material furnished by me, in whole or in part, worldwide by any means of mass and/or electronic media, including but not limited to printed, radio and television, promotional materials or events, and/or marketing plans. 

I understand that my testimonial(s) and reproduction(s) may be used in the production of
materials used to promote the Company’s programs, services and events or the Company in
general, in perpetuity. I waive any right that I may have to inspect and approve the finished
product that may be used or to which it may be applied now and/or in the future, whether that
use is known to me or unknown, and I waive any right to royalties or other compensation arising
from or related to the use of the image or product.

I, the undersigned, hereby release and agree to indemnify and hold harmless the Company, its
subsidiaries, affiliates, officers, directors, agents, owners, employees, successors and assigns
thereof, from any and all claims, actions, causes of action, damages, expenses, courts costs,
attorney fees, liability damage or judgment brought forth as a result of my participation or
materials furnished by me.

I understand that at any time I may revoke this permission by contacting the Company. This
revocation stops all future use of photos, videos and testimonials. I also understand that the
selection of production to be used, if any, is at the discretion of the Company. I also understand
that I do not have copyrights to any photographs, video or electronic reproductions made by the
Company.

I acknowledge that the material supplied by me is my own and that it has not been scripted by a
third party and that it was given by me to the Company on my own free will. I acknowledge and
affirm that any material, claim or information provided by me is true, accurate and correct, and I
agree to provide any and all requested documentation or information for purposes of verifying
such claims. I have not been paid or otherwise compensated, nor will I be compensated for my
participation or materials.

I further acknowledge that:


(1) I am a of legal age and the person identified below who is authorized to execute this
release;
(2) I have read this release in its entirety;
(3) I fully understand and accept its terms; and
(4) I have executed this release voluntarily.