Press Release Form - Missouri Academy Of Science printable pdf download

Press Release Form - Missouri Academy Of Science

MISSOURI ACADEMY OF SCIENCE

PRESS RELEASE FORM

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.

Parent/Guardian:

Signature ___________________________________________

Print Name __________________________________________ Telephone: _______________

Date ________________

Press Release Form - Missouri Academy Of Science