Multimedia Release Form - University Of California, Los Angeles printable pdf download

University of California, Los Angeles

MULTIMEDIA RELEASE FORM

Permission for Use of Name, Image and Statements

I hereby grant to The Regents of the University of California permission to reproduce my name,

likeness, identity, voice, photographic image, videographic image and oral or recorded

statements in any publication of The Regents of the University of California intended for

research, educational, promotional, fund-raising or other related use, including but not limited to,

film broadcast, printed publications, webpages and web-based publications, associated with

UCLA.

By signing this form, I waive and release The Regents of the University of California and its

officers, agents and employees, from any claim or liability relating to the use of my name,

likeness, identity, voice, photographic image, videographic image and oral or recorded

statements.

I acknowledge that The Regents of the University of California will rely on this permission and

release in producing, broadcasting, and distributing materials containing my name, likeness,

identity, voice, photographic image, videographic image or oral or recorded statements, and that

I will receive no money or remuneration of any kind from The Regents of the University of

California related to this permission and release or the materials covered by this permission and

release.

Acknowledgment of Understanding:

I have read the above “Permission for Use of Name, Image and Statements” and I fully

understand the terms. I understand that I am giving up substantial rights, including my right to

sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my

signature to be a complete and unconditional release of all liability to the greatest extent allowed

by law.

I am an adult, 18 years or older, and I have read and understand this agreement and I freely and

knowingly give my consent to The Regents of the University of California as described herein.

Participant Name (print): _________________________________________

Signature: _______________________________________________ Date: _______

IMPORTANT: IF THE PARTICIPANT IS UNDER 18 YEARS OF AGE, A PARENT OR

GUARDIAN SIGNATURE IS REQUIRED:

Parent/Guardian Name: _____________________________________

Parent/Guardian Signature: __________________________________ Date: _______

Participant's Age (if minor) ______________

Multimedia Release Form - University Of California, Los Angeles