Ambassador Submission

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Which task(s) did you complete?* This field is required.
Submit a photo with you kit
Share your story online
Submit a video testimonial
Post your testimonial on YouTube
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Upload your photo here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Upload your video here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Share the link to your video
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Share the link to your postIf multiple, separate links with a comma
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Talent Release and HIPAA Authorization to Follow* This field is required.
I understand that I cannot be considered for the program until I sign the document emailed to me after my submission. This submission does not warrant acceptance.
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SignatureFor good and valuable consideration, the receipt of which is hereby acknowledged, I hereby irrevocably grant to Butterfly Technologies, Inc. and its licensees, successors and assigns (“Company”) the right to the results and proceeds of my services rendered or to be rendered hereunder, as well as the perpetual, worldwide, irrevocable right and license to photograph, record, reproduce, transmit, telecast, and otherwise use in any manner my likeness, photograph(s), my own name or fictitious name, progress tracking photograph(s), quoted remark(s), and/or any other material based upon or derived therefrom (collectively, the “Materials”) in any manner, in any and all media now or hereafter devised, in perpetuity and throughout the universe, including without limitation, to be broadcast on television or online, for purposes of advertising, trade, display, exhibition, editorial use, or any other lawful purpose whatsoever (including, without limitation, posting the Materials on the Company's Image Library). Without limiting the generality of the foregoing, I agree that the rights granted hereunder will include the perpetual, worldwide right to edit, telecast, rerun, record, publish, reproduce, use, license, print, distribute or otherwise exploit, in any manner and in any media or forum, whether now known or hereafter devised, the Materials, in whole or in part, without any additional monetary compensation to me. I hereby irrevocably and perpetually release Company, its parents, subsidiaries and affiliates, and each of its respective officers, directors, shareholders, employees, agents, representatives, successors, licensees, and assigns (individually and collectively, “Company Entities”) from all claims and liability of any kind whatsoever, arising out of or related to, the exercise of any of the rights granted to Company above, including, without limitation, for any violation of any rights of privacy, publicity, defamation, or any other personal or property right. I hereby indemnify Company Entities against all claims, actions, losses, damages, judgments, and liabilities resulting from any breach or alleged breach by me of this release. In no event will I have any right to seek or obtain injunctive or other equitable relief with respect to Company Entities, the Project, and/or any other Company production, and/or the production, distribution, exhibition, or other exploitation thereof, and/or the advertising, promoting, or publicizing therefor. I acknowledge that the rules and regulations of any guilds or unions do not apply to this Release, and Company is not a signatory to any such entity. I acknowledge that I am an independent contractor and not an employee or partner of Company. This is the complete and binding agreement between us, superseding all prior understandings and communications with respect to the subject matter hereof. This Release cannot be terminated, rescinded, or amended hereafter, except by a written agreement, signed by all parties, and it will be exclusively governed by and construed in accordance with the laws of the State of New York applicable to agreements entered into and wholly performed therein. I warrant to Company that I am at least 18 years of age and that I have the full, complete, and unrestricted right and authority to enter into this agreement. I understand that Company will proceed in reliance hereon; however, nothing contained herein will be deemed to obligate Company to exercise any of the rights herein granted to it. PHMG MEDICAL GROUP AUTHORIZATION AND RELEASE FOR DISCLOSURE OF HEALTH INFORMATION – MARKETING Butterfly Technologies Inc. (“Paloma Health”, “we,” “us,” and “our”) contracts with Chrysalis Health of California PC, Chrysalis Health of Texas PC, Chrysalis Health of Illinois and the members of its Affiliated Covered Entity (collectively, “Paloma Health Medical Group”) regarding online telehealth medical consultations and secure messaging between Paloma Health Medical Group physicians and other healthcare professionals. Paloma Health Medical Group shares my protected health information with Butterfly Technologies, Inc. in order to provide these services. Butterfly Technologies, Inc. may use my protected health information to engage in marketing activities on behalf of Paloma Health Medical Group. By signing this authorization, I understand that Butterfly Technologies, Inc. will use my protected health information to engage in marketing activities on behalf of Paloma Health Medical Group. I hereby authorize Paloma Health Medical Group (“PHMG”) to use my image, video recording, audio recording, and personal testimony in articles, films, videotapes, books, portfolios, presentations, marketing materials and similar documents in any medium or format, including on PHMG web sites or other outlets, for PHMG’s advertising, promotional and other commercial and business purposes. I hereby consent to the storage and sharing of my image, video, and personal testimony for PHMG’s marketing, promotional, and advertising purposes. I understand that I have the right to revoke this Marketing Authorization, in writing, at any time by sending such written notification to PHMG at 386 Park Ave S, Fl 5, New York, NY 10016. I understand that information used or disclosed pursuant to this Marketing Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. However, State law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. PHMG will not condition my treatment on whether I provide authorization for the requested use or disclosure. I understand that I have the right to: inspect or copy the protected health information to be used or disclosed as permitted under Federal or State law; refuse to sign this Marketing Authorization; and receive a copy of this Marketing Authorization. This Marketing Authorization is valid until I am no longer a patient of PHMG or within ten (10) years from the date indicated below, whichever is earlier. I have read the above information and authorize PHMG to use or disclose the identified information for the purposes described herein. I understand that, by signing my name below, I release and discharge PHMG and their employees and agents from any liability relating to such use or disclosure and will hold PHMG harmless for any use or disclosure made pursuant to this Marketing Authorization. By clicking and typing your name in the boxes below, you acknowledge that you have read an agree to the terms of the PHMG Marketing Authorization. I have read and agree to the terms of the PHMG Marketing Authorization.
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