Share Your Weight Loss Success Story

First Name:
Last Name:
Age:
Original Weight:
Current Weight:
Total Weight Lost:
Email:

Before Picture:
After Picture:

Your Success Story:

I hereby grant Fit 4 Life Medical Center an irrevocable, perpetual, unrestricted, exclusive, royalty-free right and license to use, reproduce, display, sell, publish, and reuse and republish my weight loss story (my “Success Story” or “Testimonial”), including my name, relevant biographical data, other information concerning my experience with Fit 4 Life Medical Center, including my weight loss, and/or my likeness as attached in the enclosed photograph(s) and any and all Images (as defined below) of me either alone or that are accompanied by other material, now or at any time in the future, throughout the world, in any and all languages, in any manner it so chooses and in any medium now known or later developed.  Such use may include, without limitation, use on websites owned or operated by Fit 4 Life Medical Center and located on the World Wide Web, in electronic or printed newsletters, in printed materials, in advertisements in any medium now known or hereinafter discovered, in corporate brochures and in any other promotional material.  I acknowledge and agree that my Success Story and any Images may be reproduced and published in whole or in part and may be adapted in any manner by Fit 4 Life Medical Center.  I hereby waive any right to view, inspect, or approve any use of my Success Story or any Image and any materials incorporating my Success Story or any Image, and I acknowledge and agree that I will not have an opportunity to review the finalized material.  I consent to the use of any printed matter or text in conjunction with the use of any Image.  “Images” include, but are not limited to, photographs, negatives, video and digital images of me (either provided to Fit 4 Life Medical Center or taken or created in connection with the Fit 4 Life Medical Center weight management program) and any derivative works created from any Image.
 
I warrant and represent that all of the facts contained in my Success Story are true, that I am a bona fide user of Fit 4 Life Medical Center’s programs or products, that my Success Story accurately reflect my opinions and experience with respect to Fit 4 Life Medical Center and the weight loss programs offered by Fit 4 Life Medical Center, and that the Images have not been altered.  I have not used any other weight loss products or services other than those offered by Fit 4 Life Medical Center in achieving the weight referenced in the Testimonial and, if applicable, since I achieved such weight. I acknowledge and agree that I have the exclusive right and authority to grant the license granted herein to use my Success Story and any Images. I acknowledge and agree that all materials of any kind supplied by me to Fit 4 Life Medical Center, including without limitation, written materials and Images in any medium, will become the property of Fit 4 Life Medical Center and will not be returnable.
 
I acknowledge and agree that there are to be no fees, commissions, or royalties paid to me for the use of my Success Story or any Image by Fit 4 Life Medical Center and that I am not due any compensation of any kind from Fit 4 Life Medical Center. I acknowledge that Fit 4 Life Medical Center is under no obligation to use my Success Story or any Image.
 
In the event that Fit 4 Life Medical Center elects to use my Success Story, in consideration of such use, I agree that I will not hold Fit 4 Life Medical Center or any of its directors, employees, shareholders, affiliates, agents or weight loss program providers (the “Released Parties”) responsible for, and hereby release the Released Parties from, any loss or liability resulting from or related to the use of my name, my Success Story, and/or any Image. I acknowledge that Fit 4 Life Medical Center cannot prevent unauthorized third parties from downloading, copying and/or distributing my name, my Success Story and/or any Image from the internet.
 
If any provisions of this authorization form are invalid, the remaining provisions continue in full force and effect.  The laws of the State of New York govern this document.  I warrant to Fit 4 Life Medical Center that I am at least 21 years of age and have the right and authority to make this Release.  I agree to notify Fit 4 Life Medical Center in the event that I am no longer using Fit 4 Life Medical Center’s products or services.

I agree to the Terms of Service

Share Your Success Story