PERSONAL RELEASE FORM

 

“VDRDC Informational Video Project”

(Project Working Title as of 03/21/2012)

 

 

Participant Name (printed):_________________________________

 

Address: _____________________________________________________________

 

Telephone: _______________

 

Email: _________________________

 

 

I, the undersigned, hereby grant permission to Producers Dr. Joshua Miele, Owen Edwards, Ana Forest, and Benoit Lacasse (hereinafter known as ‘the Producers’) to record video, photographs, sound, speeches, interviews and appearances of me and to distribute or exhibit the same in whole or in part, in any medium and for any purpose whatsoever, including promotion and advertising.

 

I understand that the Producers’ records of me will be maintained and made available indefinitely by the Producers for such research, production (World Wide Web, exhibitions, related advertisements, radio, television, DVDs, promotional reel … ), and educational purposes as the Producers shall determine.

 

I hereby grant, and transfer to the Producers all rights, title, and interest in the interview and video documentary as well as the right to use my name in connection therewith if they so choose.

 

I hereby release and discharge the Producers from any and all claims and demands arising out of or in connection with the use of the audio-video footage, including any and all claims for libel and allow him to copyright the same in the producer’s name or any other name that he may choose.

 

I am over the age of eighteen. I have read the foregoing and fully understand the contents thereof.

 

 

Signature : _________________________ Date________

Dr. Joshua Miele-  VDRDC – Smith-Kettlewell Eye Research Institute

jam@ski.org