MSD Photo & Video Release

I hereby grant to Merck Sharp & Dohme (I.A.) LLC (Philippine Branch) (“MSD”), with address at 26/F
Philamlife Tower, 8767 Paseo de Roxas, Makati City 1226, the right to photograph and/or
videotape/record (in audio-visual format) me and further grant the right to use my image, likeness,
and name (including such photographs and audio-video recordings) for the specific purpose of
sharing my experience and actual testimonial on Bakunado si Lolo’t Lola Iwas Pulmonya in Ormoc in
any and all media, including digital media, throughout the world.

I understand and agree that MSD shall own all rights over the finished product, including any
subsequent alterations (the “Materials”). I waive any right to royalties or other compensation arising
or related to the use of my image, likeness, and name, whether as used in the Materials or otherwise.

Use of Materials

I understand that MSD shall determine the use of the Materials which may include using or publishing
the Materials on its website, the internet, in billboards, trade fairs, and other public exhibitions,
newspapers, magazine, television and similar media. MSD shall also have the right to use the Materials
in its internal and external engagements such as but not limited to press conferences, media
interviews, lay engagements, digital executions, scientific meetings and advocacy campaigns.

MSD shall have the right to alter the Materials, add to, or combine the same with any other photos,
drawings, or effects at its sole discretion.

Such use may be local and/or international and I consent to this use in other countries, including
countries which may have data protection laws less strict than the laws in the Philippines.

Your right to review and approve the Materials

MSD will provide the Materials to me for approval prior to releasing them to the public. I agree to
review the Materials and provide any feedback to MSD within 30 days from receipt of such materials.
If I do not provide any feedback to MSD within such period, MSD will be free to use the Materials on
the terms set out in this document.

Duration of Use

MSD will have the right to use the Materials as stated in this form for a period of one (1) year from
the date of this document. Should MSD wish to extend the period for the use of the Materials, another
consent form from me, allowing such, shall be required.

Release

I hereby release and discharge MSD and its agents, its subsidiaries, affiliates, officers, employees and
licensees from any and all claims, actions and demands arising out of or in connection with the use of
the Materials.

Name (Print) _______________________________________________________________________

Signed _________________________________________ Date ______________________