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Photograph & Video Release Form
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or
video tape without payment or any other consideration. I understand that my image may be edited, copied,
exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my
likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the
use of my image or recording. I also understand that this material may be used in diverse educational
settings within an unrestricted geographic area.
Photographic, audio or video recordings may be used for the following purposes:
 conference presentations
 educational presentations or courses
 informational presentations
 on-line educational courses
 educational videos
By signing this release I understand this permission signifies that photographic or video recordings of me
may be electronically displayed via the Internet