Certification and Authorization; Release of Information

I hereby certify that with respect to my grant application submitted to A Damn Good Life (“ADGL”), all of the information provided is complete, truthful and accurate to the best of my knowledge. In the event of any change in such information (including my household income, household circumstances or insurance status), I immediately shall notify ADGL of any such changes or inaccuracies and update the information accordingly.

I hereby authorize my physicians, pharmacists, and any other medical, fertility, drug, treatment or insurance providers to disclose, discuss, or release, verbally or in writing, to ADGL, along with its representatives or agents, patient or medical information relating to: (i) my treatment for breast cancer; and (ii) other relevant health information, strictly for the purpose of assessing my eligibility and application for funds from ADGL in connection with my surrogacy journey and/or making payment of funds on my behalf to providers who are a part of my surrogacy journey.

I understand that submission of this application does not guarantee a grant of funds from ADGL, and that my eligibility and application for funds are subject to ADGL’s approval in its sole discretion, including the right, without prior notice, to reject my application, modify any amount of funds approved, or terminate in full any otherwise-awarded funds.

I understand that ADGL is not a surrogacy agency, legal counsel or medical provider related to surrogacy. By submitting this application, I acknowledge and agree that ADGL shall not have any legal, financial or other liability or responsibility with respect to any acts, events, omissions or commissions relating to: (i) my current and future medical treatment; (ii) ADGL’s acceptance or rejection of my grant application; or (iii) any funds awarded in connection therewith.

I understand that there is no guarantee that any medical procedure (such as embryo transfer) or drugs provided, recommended, prescribed or intended to assist in a healthy pregnancy for the surrogate will be successful, and I agree that ADGL shall not be liable for any actual or perceived failure of any embryo transfer or pregnancy.

I understand that ADGL is not responsible for any of the following expenses in relation to the surrogacy journey: (i) travel expenses; (ii) payments to a surrogate beyond her surrogacy fee; (iii) insurance or supplemental insurance for the surrogate; or (iv) lost wages. Any additional fees outside the terms of a grant agreement are subject to ADGL’s approval.

I acknowledge that the medical services or other procedures in connection with use of grant funds from ADGL may involve activities that are inherently dangerous (including without limitation, activities that may present threats to my health and life, and/or strenuous physical activity), and I hereby voluntarily assume any and all risks, known or unknown, in connection with such funding. I agree to defend, indemnify and hold harmless and to voluntarily release, discharge, waive and relinquish any and all actions or causes of action against ADGL, from any and all claims, demands and liabilities (including, but not limited to, personal injury, bodily harm, property damage, theft, emotional distress and wrongful death) resulting in any manner from my receipt of grant funding.

I understand the scope of my release set forth herein shall include, but not be limited to, those based on negligence, products liability, breach of contract (excluding breach of this agreement), breach of any statutory or other duty of care owed under applicable laws, libel, slander, defamation, invasion of privacy, right of publicity or personality, misappropriation, intentional infliction of emotional distress, negligent infliction of emotional distress and infringement of copyright. I hereby unconditionally and irrevocably agree that I will not file suit or otherwise pursue any such claims against ADGL.