Thank you for participating in Sink or Swim with HOYA 2017! The promotion is going to be a ton of fun. We had more than 100 winners in 2016 and we are looking forward to you being a winner too. Even fun promotions are subject to the usual legal documentation. Please take the time (15 to 20 minutes) to read review and complete ALL of the information below. We know some of it will be repetitive, hang in there, it will be worth it!

* 1. How did you hear about the Sink or Swim 3.0 with HOYA promotion?

* 2. Is there anyone else at the practice who should receive the updates and tips? Please enter their email addresses here:

* 3. HOYA Account Number:

* 4. Contact Information

* 5. I (enter your name below)

, will participate in an exclusive Program called “Sink or Swim with HOYA” conducted by Hoya Vision Care, NA. The Program involves my participating in the Sink or Swim program to take place from October 1, 2017 to March 31, 2017 (the “Program”) for an opportunity to earn a Prize, a cruise and airfare valued up to $3,000.00 USD (the “Prize”). In consideration for allowing me to participate in the Program and for a chance to earn a Prize, I understand and agree to the following:
The name above states you are an owner or partner in the practice and authorized to accept the Prize on behalf of the practice. Authorized owners or partners may transfer the Prize. For purposes of this Release Agreement, the “Released Parties” shall mean any person or entity associated in any way with the Program, including but not limited to Hoya Vision Care NA, the Program’s sponsoring organizations, any operators, managers of the Program, and each of their respective parents, subsidiaries, affiliates, officers, directors, employees, agents, volunteers and contractors. Furthermore, for purposes of this Release Agreement, the term “Loss” shall mean all damages, losses, costs, and injuries of every kind and character including, but not limited to, all property and economic damages, diminution of value, loss or use, loss of business opportunities, loss of value, embarrassment, mental anguish, loss of consortium, loss of services, loss of companionship, and loss of employment. I represent that the above information concerning me is accurate.
Neither I nor any member of my family was or is an employee of HOYA Vision Care NA, or their respective owner, parent, or subsidiary, throughout the duration of the Program. I understand the conditions associated with participation in the Program and qualifications for earning a Prize. Criteria for earning a prize is at the sole discretion of HOYA Vision Care and can change at any time for any reason. I warrant that I am under no constraints that would prevent me from participating in the Program. IN CONSIDERATION OF YOUR ALLOWING ME TO PARTICIPATE IN THE PROGRAM, I EXPRESSLY AND VOLUNTARILY ASSUME RESPONSIBILITY FOR ALL RISK OF PROPERTY DAMAGE, PERSONAL INJURY, DEATH, OR LOSS I MAY SUSTAIN RELATED TO THE PROGRAM OR RECEIPT OF PRIZE, OR ANY SUCH PROPERTY DAMAGE, PERSONAL INJURY, DEATH, OR LOSS ASSOCIATED IN ANY WAY WITH THE PRIZE, EVEN IF SUCH PERSONAL INJURY, DEATH, OR LOSS IS CAUSED, IN WHOLE OR IN PART, BY THE NEGLIGENCE OR GROSS NEGLIGENCE OF ANY OF THE RELEASED PARTIES. I hereby acknowledge and agree that the Prize is (are) my sole and only prize if I earn the Prize in the Program. I acknowledge and agree that the Released Parties are not acting as the manufacturer or distributor of the Prize. The Released Parties, acting as consumers, acquired the Prize for the purpose of awarding it to a winner in the Program. I acknowledge and agree that I am responsible for any taxes and fees of any type associated with my receipt and/or use of any Prize including, without limitation, income taxes and sales and use taxes, and any expenses associated with any Prize which are not specifically noted. I authorize the Released Parties to withhold from any cash Prize any amounts required to be withheld pursuant to federal, state or local law. I understand that the value of the Prize is based on available information provided to the Released Parties, and I waive any claim I may have against the Released Parties regarding the valuation of the Prize.
Discounts, Rebates, Price Concessions: Any discounts, rebates, or other price concessions referenced herein are intended to reflect discounts or other reductions in price within the meaning of the discount exception to the federal anti-kickback statute (42 U.S.C. §1320a-7b(b)(3)(A)). In addition, any value provided to Customer under the warranties referenced in this Agreement shall be provided in accordance with the provisions of the federal anti-kickback statute warranty safe harbor regulation (42 C.F.R. §1001.952(g)). Federal anti-kickback law provides for criminal and or/civil liability for Inducements related to any product for which payment may be made by a federal healthcare program or federally-funded state healthcare program, including Medicaid and Medicare (collectively, “Federally Funded Programs”). Some states have similar anti-kickback laws (“State Laws”). It is Hoya’s policy to comply with all applicable laws; however, Hoya has no way of knowing whether any specific transaction will be paid by a Federally Funded Program or otherwise covered by State Laws. Accordingly, it is the participant’s sole responsibility to determine if a job is eligible or not eligible under this Agreement, and notify Hoya of any transactions which should be excluded (including any transactions with third-party private payers which may be prohibited under State Laws or as a result of participation in Federally Funded Programs), and to ensure that the participant does not accept any benefits under this Agreement that are prohibited. ANY TRANSACTION FOR WHICH PAYMENT WILL BE MADE, IN WHOLE OR IN PART, BY ANY FEDERALLY FUNDED PROGRAM, OR WHICH IS OTHERWISE COVERED BY STATE LAWS, IS NOT ELIGIBLE FOR PARTICIPATION IN THIS AGREEMENT. Hoya will provide the value of any discounts, rebates, or other price concessions, including use of equipment at no charge, to Customer so that Customer can comply with its obligation to properly disclose and appropriately reflect such discounts, rebates, or other price concessions on applicable cost reports or in charges to Medicare, Medicaid, and other federal health insurance programs or state health insurance programs in accordance with Section 1128B(b)(3) of the Social Security Act, 42 U.S.C. §1320a-7b(b)(3). If Customer requires any further information, Customer may contact Hoya, and Hoya will provide such information to Customer. 

With respect to any claims I may have as a result of the Prize, I covenant that I shall look solely to the manufacturer of the Prize, or others in the chain of production and distribution of the Prize, but excluding the Released Parties, their respective employees and/or affiliates. I acknowledge and agree that the Released Parties have not made any warranties with respect to the Prize.
I acknowledge and agree that the Released Parties may subsequently use for publicity and/or promotional purposes, my name, likeness, photographs, videotapes or other recordings of me participating in the Program, without any additional consideration to me beyond allowing me to participate in the Program for a chance to win any Prize(s).

I acknowledge and agree the release I have granted herein shall extend to and protect the agents, employees, representatives, assigns and successors in interest of the Released Parties.

I certify I am over the age of 18 and am legally competent to sign this Release Agreement and I understand that the representations contained in this Release Agreement are contractual and not mere recital. I have fully informed myself of and understand the contents of this Release Agreement and I have signed this document of my own free act.

This Release Agreement and any claims associated with it, the Program shall be construed according to Texas law. I acknowledge and agree that the Contest, Event and/or this Release Agreement is being performed, in whole or in part, in Denton County, Texas and venue and jurisdiction for any claims associated in any way with this Release Agreement shall only be proper in the District Court for the County of Denton, State of Texas.

If any provisions of this Release Agreement shall be deemed to be unenforceable and/or void, the remainder of this Release Agreement shall not be affected thereby and the remainder of this Release Agreement shall be fully enforceable.

In the event the Official Contesting Rules & Regulations, or any other agreement related to the Program conflicts with any provision contained herein, this Release Agreement shall control.

* 6. Please acknowledge you read the statement above by putting your initials here:

I, FOR MYSELF AND MY PERSONAL REPRESENTATIVES, HEIRS, SUCCESSORS, AND ASSIGNS, IN CONSIDERATION FOR BEING INVOLVED IN THE PROGRAM AND A CHANCE TO EARN THE PRIZE, HEREBY HOLD HARMLESS, RELEASE, INDEMNIFY AND DISCHARGE FROM LIABILITY THE RELEASED PARTIES FROM ALL LIABILITY, CLAIMS, JUDGMENTS, DEMANDS, CONTROVERSIES, AGREEMENTS, DAMAGES, ACTIONS, AND CAUSES OF ACTION WHATSOEVER, ARISING OUT OF OR RELATED IN ANY WAY TO THE PROGRAM, AND/OR THE PRIZE, WHETHER IN LAW OR EQUITY, NO MATTER WHAT THE CAUSE OR NATURE, AND I FURTHER WAIVE ANY CLAIM THAT I MIGHT STATE OR ASSERT AGAINST ANY OF THE RELEASED PARTIES WHICH I HAVE OR MAY HAVE AT ANY TIME ARISING OUT OF MY ASSOCIATION WITH, TRAVEL TO OR FROM, OR PARTICIPATION IN THE PROGRAM, OR ANY OF ITS ASSOCIATED ACTIVITIES, OR IN ANY OTHER WAY RELATED TO OR RESULTING FROM THE PROGRAM OR ANY PRIZE. I ACKNOWLEDGE AND UNDERSTAND THAT BY SIGNING THIS RELEASE AGREEMENT I WILL LOSE ANY RIGHT I MAY HAVE HAD TO SUE ANY OF THE RELEASED PARTIES BECAUSE OF ANY PERSONAL INJURY, DEATH, OR LOSS I MAY SUSTAIN WHILE USING THE PRIZE, OR ARISING OUT OF OR AS A RESULT OF MY PARTICIPATION IN THE PROGRAM, EVEN IF SUCH PERSONAL INJURY, DEATH, OR LOSS RESULTS FROM OR IS CAUSED BY THE NEGLIGENCE OR GROSS NEGLIGENCE OF ANY OF THE RELEASED PARTIES, IN WHOLE OR IN PART. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY CLAIM ARISING OUT OF MY PARTICIPATION IN THE PROGRAM, EVEN IF THE CLAIM ARISES OUT OF THE NEGLIGENCE OR GROSS NEGLIGENCE OF THE RELEASED PARTIES, IN WHOLE OR IN PART, INCLUDING, WITHOUT LIMITATION, ALL CLAIMS BROUGHT OR ASSERTED BY ANY THIRD PARTY AS A RESULT OF ANY PERSONAL INJURY, DEATH, OR LOSS I MAY SUSTAIN.

I ACKNOWLEDGE AND AGREE THAT THE RELEASE I HAVE GRANTED HEREIN INCLUDES, WITHOUT LIMITATION, ALL DERIVATIVE CLAIMS, INCLUDING BUT NOT LIMITED TO, LOSS OF CONSORTIUM, LOSS OF SERVICES, AND LOSS OF COMPANIONSHIP, WHICH ARISE OUT OF ANY PERSONAL INJURY, DEATH, OR LOSS I MAY SUSTAIN WHILE PARTICIPATING IN THE PROGRAM, OR USING THE PRIZE, OR ARISING OUT OF OR AS A RESULT OF MY PARTICIPATION IN THE PROGRAM, OR USE OF THE PRIZE, WHICH MIGHT BE STATED AND/OR ASSERTED IN ANY FORUM BY MY SPOUSE, CHILDREN, FRIENDS, FAMILY, LOVED ONES, AND/OR OTHER THIRD PARTIES.

I ACKNOWLEDGE AND AGREE THAT I: (1) HAVE RECEIVED A COPY OF THIS RELEASE FOR REVIEW AND STUDY AND HAVE HAD AMPLE TIME TO REVIEW IT BEFORE SIGNING; (2) HAVE READ THIS RELEASE CAREFULLY; (3) HAVE BEEN GIVEN A FAIR OPPORTUNITY TO DISCUSS AND NEGOTIATE THE TERMS OF THIS RELEASE; (4) UNDERSTAND ITS PROVISIONS; (5) UNDERSTAND THAT I HAVE THE RIGHT TO CONSULT WITH AN ATTORNEY; (6) HAVE DETERMINED THAT IT IS IN MY BEST INTEREST TO ENTER INTO THIS RELEASE; (7) HAVE NOT BEEN INFLUENCED TO SIGN THIS RELEASE BY ANY STATEMENT OR REPRESENTATION BY THE RELEASED PARTIES NOT CONTAINED IN THIS RELEASE; AND (8) ENTER INTO THIS AGREEMENT KNOWINGLY AND VOLUNTARILY.

* 7. Signature. By typing your name here you acknowledge this is your esignature. Please place an "/s/" in front of your typed name, e.g. /s/Ashley Brennan

* 8. Date here:

* 9. You have the option to NOT sign electonically. By clicking below you have opted to not use an esignature.

Consent to do business electronically: The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Opt- out Clause: You may withdraw your consent to receive this electronic agreement. In order to withdraw consent, you must notify the sending party that you wish to withdraw consent and request the agreement be provided in paper format. Please contact the sending party by telephone, postal mail or email.
HOYA reserves the right to modify or cancel the program at any time, prior to or during the duration of the program. Entrants will be notified in the event of program cancellation prior to the official start date of October 1, 2017.

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