Authorization for Disclosure and Use of Images

To assist Genzyme Corporation ("Genzyme") in providing information about Pompe disease, I will allow Genzyme, its employees, and its agents to disclose (1) photographic images of me and/or (2) photographic images in which I may be included, and/or to the public in educational materials. Such materials may include, but are not limited to, the following:

  • materials distributed to the media for publication within articles or television reports;
  • images which may be shared with, physicians and patients; and
  • presentations distributed via the internet.

Should Genzyme desire to alter or edit my Images, I will be notified and my approval will be requested prior to such alternations or edits.

I will not be compensated in any way unless agreed to in writing by myself and Genzyme or its agent.

This Authorization shall remain in effect for ten (10) years or until revoked (taken back) by me. I may revoke this Authorization at any time by sending a letter that includes my name and address to Genzyme Corporation, Attn: Katy Bonnin, 500 Kendall Street, Cambridge, Massachusetts 02142. However, I understand that revoking (taking back) the authorization will not affect any use or disclosure of the Images made before my revocation is received and processed.

I agree to hold harmless Genzyme, its employees, and its agents (including any firm publishing and/or distributing the finished product) from liability that may arise from the disclosure of my images.

I may receive a copy of this Authorization and agree that a photocopy is as valid as the original.

I have read and understood the contents of this Authorization before signing below.