Level 5 Media Release Form

I hereby voluntarily enter into this release of all below-listed rights (the “Release”) as of the signature date (the “Effective Date”) as an interviewee/workshop participant for Clarity Breathwork, Dana Delong & Ashanna Solaris.

In consideration of my engagement as a participant in Clarity Breathwork, I hereby grant to Clarity Breathwork and each of its officers, directors, employees, shareholders, agents, licensees, affiliates, parents, subsidiaries, any successor company and those acting with their authority (collectively referred to as “Clarity Breathwork”), the absolute and exclusive right and permission, limited to the contents of this one event one production, throughout the world to copyright, use, re-use, sub- license publish and republish photographic portraits, pictures, silhouettes, sketches, drawings, caricatures or any likeness of me or in which I may be included, in whole or in part, that emanate from the photography/videography session contemplated in conjunction with the photo/video shoot – (collectively known as “Media Materials”), without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or any reproduction thereof made through any of the media hereinafter listed for advertising trade, commercial, publicity, copyright purposes, web content or any other purposes whatsoever in connection with “Clarity Breathwork.” We reserve the right to use any image of me and content of the videography or photography taken pursuant to this Agreement.

I hereby waive any right that I may have to inspect and/or approve any finished product or products, including but not limited to those for media-use, or any advertising copy, or printed matter in which I am featured pursuant to the terms hereof.

Any production or reproduction made using me, shall not intend or in actuality cause disrepute to or disparage me or any third party with which I am associated.

In addition I hereby confirm that I am lawfully exercising my right of publicity, only in connection with the grant given hereunder, and I accept and acknowledge that such grant allows Clarity Breathwork to use my likeness or other attributes of identity as described herein above for advertising, commercial and/or trade purposes.

I understand that this authorization and release is also binding upon my personal representatives and successors in interest.

I understand there shall be no payment for this release.

I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Please fill out and submit the form below to complete the agreement.