CPAP, Sleep Apnea, Sleep Disorders, CPAP Story

Permission/Submission of YOUR Story

I hereby grant permission to the Sleep Wellness Institute of West Allis, Wisconsin, to publish my story about my experience on CPAP therapy on the website www.shareyourCPAPstory.com. I understand that only my first name and my city of residence will be used.

I further grant permission to the Sleep Wellness Institute to submit my video story to the website You Tube, and others, again using only my first name and city of residence.

I understand that the Sleep Wellness Institute will solely determine if my story is to be recorded on video. If so, the Sleep Wellness Institute will send me a flip video camera on which I will record my story. I further understand that once I submit my video to the Sleep Wellness Institute, said video becomes the property of the Sleep Wellness Institute and I will surrender all rights to publish it on any website anywhere.

I further understand that I must provide a valid credit card number to the Sleep Wellness Institute before receiving the flip video camera. My card will NOT be charged unless I fail to use it and submit my story to the Sleep Wellness Institute within thirty (30) days of my receipt of such flip video camera. Should I fail to submit my video within said time frame, I authorize the Sleep Wellness Institute to charge a fee of $125 to my credit card.

I have read and understand all of the above and wish to proceed. My written story is submitted below. By placing an X in the box below, I am granting my written permission to the Sleep Wellness Institute to proceed.

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By placing an X in this box, I hereby state that I am at least 18 years of age and grant my permission to the Sleep Wellness Institute to proceed with this project.

Your name: *

Address: *

City: *

State: *

Zip Code: *

Email address: *

Phone number: *

Your story: *

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