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Photograph And Video Release Form

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Photograph & Video Release Form

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or

video tape without payment or any other consideration. I understand that my image may be edited, copied,

exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my

likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the

use of my image or recording. I also understand that this material may be used in diverse educational

settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:

• conference presentations

• educational presentations or courses

• informational presentations

• on-line educational courses

• educational videos

By signing this release I understand this permission signifies that photographic or video recordings of me

may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those

listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these

materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this

document only.

By signing this form I acknowledge that I have completely read and fully understand the above release and

agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing

this material for educational purposes.

Full Name___________________________________________________

Street Address/P.O. Box________________________________________

City ________________________________________________________

Prov/Postal Code/Zip Code______________________________________

Phone ___________________________ Fax _______________________

Email Address________________________________________________

Signature____________________________ Date____________________________

If this release is obtained from a presenter under the age of 19, then the signature of that presenter’s parent or

legal guardian is also required.

Parent’s Signature_____________________ Date____________________________

Photograph And Video Release Form

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