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Tell Your Story


Please fill out the form, and tell us your story.
First Name:  
Last Name:  
Email:  
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City/State:  
Age (years):
What Hurts:  
Story:  

I authorize The Hygenic Corporation ("Hygenic"), its employees, agents, successors, assigns, subsidiaries and/or affiliates the right and permission to copyright and/or use and/or publish and republish in any medium, my name, image and/or likeness in a still photograph and/or full-motion video and/or product testimonial in whole and/or in part, ("Materials") and do so without expectation or obligation of compensation or remuneration in the aforementioned uses.

This Material may be used with or without using my name or by using my initials. Hygenic may use the Material in its entirety or in part, at its own discretion. I understand that the publication or otherwise use of the Material is not subject to my inspection or approval, after initial approval is given. The Material may be used in various forms of media, including print, visual or audio.

I agree that, other than any goodwill or publicity that I may receive relating to the publication, distribution or other use of the Material, I will not be compensated for use of the Material. Any Material supplied to and/or taken by Hygenic shall be and remain the property of Hygenic. Hygenic shall have the right to use, copy, modify, adapt, distribute, publish, display, exhibit and otherwise use the Material, in whole or in part, for commercial and business purposes.

I release, discharge and agree to hold harmless Hygenic, its employees, legal representatives or assigns, and all persons acting under their authority from any liability that may occur from the use of the Material or in its subsequent publishing or processing thereof. I also agree to hold harmless Hygenic in the event that I submit Materials that are not returned to me.

I state that I have submitted information that it is true and accurate. I also state that I have the authority to use and submit any Material given to Hygenic. I acknowledge that I am at least eighteen years of age. I understand that if I am less than eighteen years of age that my parent or guardian must authorize the release of this information. I also state that I have not given any person or entity the exclusive right to use my name, life story, picture or any other information. This release shall be binding upon me and my heirs, legal representatives and assigns.

I have read and agree to the these terms.