Fillable Release For Adults - Girl Scouts Of The Usa printable pdf download

DATE(s): _______________________________________________________________________

PHOTOGRAPHER/PRODUCER: ____________________________________________________

ASSIGNMENT: ___________________________________________________________________

COUNCIL (IF APPROPRIATE): ______________________________________________________

LOCATION: _____________________________________________________________________

ACTIVITY: _____________________________________________________________________

RELEASE FOR ADULTS

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and

agree to the following:

I acknowledge that I am eighteen (18) years of age or older. I hereby grant to Girl Scouts of the USA (“GSUSA”),

and others working for GSUSA or on its behalf, and each of its respective licensees, successors and assigns (each a

“Releasee”), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit,

digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness

and voice (including any video footage of the same) (collectively, “Media”), or to refrain from so doing, anywhere in the

world, by any persons or entities deemed appropriate by GSUSA, for any purpose (except defamatory) including, without

limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media

whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store

and via television. I agree that I have no interest or ownership in any of the Media.

I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims

based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary

effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will

create any obligation on GSUSA to make any use of the Media or the rights granted in this Release. I hereby release and

hold harmless Releasees from any claim for injury, compensation or negligence resulting or arising from any activities

authorized by this Release and any use of the Media by GSUSA.

SIGNATURE:______________________________________________________________________________________

NAME (please print):________________________________________________________________________________

DATE:___________________________________________________________________________________________

HOME ADDRESS:___________________________________ CITY________________ STATE_____ ZIP__________

DAYTIME PHONE: (_____)_____________________ ADDITIONAL PHONE (optional): (____)_____________________

EMAIL ADDRESS*:___________________________@____________________________

(*will not be used for any other purposes or distributed to third parties)

______________________________________________________________________________________________________

Any revisions to the text of this Release must first be approved in writing by GSUSA

prior to the activity in order for the changes to be effective.

7/2010

Release For Adults - Girl Scouts Of The Usa