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Collaborative Summer Library
953 6th Place SE
Mason City, IA 50401-5261

641-423-0005 voice
641-424-5120 fax
866-657-8556 toll free

Model Release Form for Publication and Video Purposes for the Teen Video Challenge
This release is a binding contract between the undersigned and Collaborative Summer Library Program (“CSLP”). It insures to
the benefit of and binds both parties’ heirs, successors, representatives and assigns.
Each member of a team that submits a video or, who appears in the video, must sign a release.
Subject of Release. “Material” refers to all video, images, photographs, mixed media, music, text and other forms of
copyrighted material that I supply to CSLP.
License. I grant CSLP an irrevocable, perpetual, world-wide, royalty-free, sub-licensable, transferable, non-exclusive license to
use, reproduce, distribute, publish, prepare derivative works, display, perform, and otherwise exploit the Material in any media
Name and Likeness.