Tell us about you

Are you a resident of the United States?

Are you 18 years of age or older?

Tell us about your Change Agent nominee

Is the person you are nominating a resident of the United States?

Which of the following choices best describes the impact your nominee has had on your family’s life with LGS? These descriptions will be shared with your nominee in an email once your submission is complete.

Select all that apply:

Submit your nomination, and share with your nominee

CONSENT AND RELEASE REGARDING PERSONAL INFORMATION

×

By checking the “I agree” box below this Consent and Release, I irrevocably grant to Lundbeck LLC (“Lundbeck”), its affiliates, subsidiaries, successors and assigns, the right (and all copyrights accruing thereto) to use and disclose my biography, interview, likeness, voice, and personal health information that I provide to Lundbeck (“My Information”), at Lundbeck’s sole discretion, and to incorporate My Information into any publications or presentations for the benefit of Lundbeck and to use or authorize the use of such publication or any portion thereof, in any other manner or media at any time or times throughout the world in perpetuity, including promotion in printed media, and online (including but not limited to at LGSChangeAgent.com, Twitter and Facebook). 

I hereby assign: all my right, title, and interest; the rights to pursue all causes of action for copyright infringement, trademark infringement, violation of moral rights, unfair competition, or arising from any other rights relating to My Information, and all results and proceeds from any of the rights assigned hereunder, to Lundbeck.   I hereby release and discharge Lundbeck, its respective successors, assigns, licensees, employees, and agents, from any and all liability or claims known and unknown arising out of the rights granted hereunder, or the exercise thereof, including, but not limited to, claims relating to any distortion or alteration, whether intentional or otherwise, that may occur or be produced in connection with any processing, alteration, transmission, display, publication, or other use of My Information.

I confirm that I have the right to enter into this Consent and Release and that I am not restricted from doing so by any commitment(s) to third parties.

I understand and agree that I will not receive royalties or other compensation, monetary, in-kind, or otherwise, in exchange for this Consent and Release.  This Consent and Release will be binding upon my heirs, successors, representatives, and assigns.

I understand that by signing this Consent and Release, I will give up substantial rights.  By checking the “I agree” box, I confirm that I am agreeing to give up such rights, and I am doing so freely and without any inducement or assurance of any nature.  

I have had an opportunity to ask questions regarding the use of My Information and I have reviewed the Lundbeck Privacy Policy and agree to its terms.  I understand that I may withdraw my consent at any time by writing to Lundbeck at 6 Parkway North, Deerfield, IL, 60015 or contacting them via this online form, but that if I do withdraw my consent, that will not affect any uses or disclosures occurring prior to the receipt by Lundbeck of my written withdrawal of consent.

View Full Agreement

Tell us about your Change Agent nominee

Submit your nomination, and share with your nominee