Questionnaire Information Release

I understand that Julie Reynolds Gillespie (the “Author”) is preparing, writing and will publish a work on the subject of triplets, which is currently titled....

In order to assist the Author in the preparation of the Work, I have agreed to complete the Mother of Triplets Questionnaire and provide the information requested therein to be used in connection with the Work (the “Questionnaire Information”).

I hereby affirm that I am over the age of majority and will provide true and accurate Questionnaire Information.

I hereby grant and assign to the Author and her licensees, successors, and assigns the following rights in connection with the Questionnaire Information for use as part of the Work in any and all editions, versions, and media, in perpetuity and throughout the world.

1. The right to use and publish the Questionnaire Information in a non-personally indentifiable manner separately or in the aggregate with information provided by others who have completed the Mother of Triplets Questionnaire.

2. The right to use, develop, produce, distribute, advertise, promote or otherwise exploit the Questionnaire Information as part of the Work in any manner that the Author or her assigns deems appropriate.

3. I understand and acknowledge that the Author or her assigns is or will be the sole owner of all copyright and other rights in and to the questionnaire, the questionnaire containing the completed Questionnaire Information (the “Completed Questionnaire”) and the Work. Furthermore, I hereby expressly grant and assign to Author all rights, title and interest of any kind and nature in and to the Completed Questionnaire, and I agree (i) not to claim any ownership interest in the Completed Questionnaire or any copyrighted material therein; and (ii) not to use or exploit or claim the right to use or exploit the Completed Questionnaire in any manner.

In order to enable the Author to develop the Work in any manner that the Author may deem best, I hereby release and discharge the Author and her licensees, successors and assigns, from any and all claims, demands, or causes of action that I may have against them by reason of anything contained in the Work, or any of the above uses, including, without limitation, any claims based on the right of privacy, the right of publicity, copyright, defamation, libel, slander, or any other right.

Agreed and Confirmed: