Press Release Form - Missouri Academy Of Science


Bring to Registration Desk April 22, 2016
The undersigned hereby irrevocably consents to and authorizes the use
Attach a wallet sized
by Missouri Academy of Science, (“Academy”) its officers and
photograph with your
employees of the undersigned’s image, voice and/or likeness as
name and school printed
follows: The Academy shall have the right to photograph, publish, re-
on the back.
publish, adapt, exploit, exhibit, perform, reproduce, edit, modify, make
derivative works, distribute, display or otherwise use or reuse the
undersigned’s image, voice, and/or likeness in connection with any
product or service in all markets, media or technology now know or hereafter developed in
Academy products or services, as long as there is no intent to use the image, voice and/or
likeness in a disparaging manner. The Academy may exercise any of these rights itself or
through any successors, transferees, licensees, distributors or other parties, commercial or
nonprofit. The undersigned acknowledges receipt of good and valuable consideration in
exchange for this Release, which may simply be the opportunity to represent the Academy in its
promotional and advertising materials as described above.
Please indicate your agreement to the foregoing by signing below.
Signature _______________________________________________
Print Name _______________________________________ Telephone: _________________
Address______________ ______________________________________________________
Date ____________________
If you are under eighteen (18) years of age, your parent or guardian must sign below:
I represent that I am a parent/guardian of the minor who has signed the above release and that in
that capacity Missouri Academy has my consent and authorization to use the name, voice and/or
likeness as described above.
Signature ___________________________________________
Print Name __________________________________________ Telephone: _______________
Date ________________


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