Photograph, Video and Audio Model Release Form

Photograph / Video (Film) / Audio Model Release Form

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby grant permission to Consolidated Shoe Company, Inc. and its agents or employees to use photographs and/or video and audio taken of me.  These images may be used in educational and documentary materials such as Public Service Announcements, Grant Applications, Video Documentaries and both printed and online mediums.  Furthermore, I authorize the use of my image, likeness, and voice for all program promotion, materials, and any other purposes, both non-commercial and commercial, in connection with the program deemed appropriate and/or necessary by Consolidated Shoe Company, Inc.

I hereby agree to release, defend, and hold harmless Consolidated Shoe Company, Inc and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, including, but not limited to paper, broadcast, videotape, or via electronic/online media, from any claim, damages, or liability arising from or related to the use of the photographs/video, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution.

I do hereby guarantee that any information about the teaching scenarios, simulation exercises, and the performance of other learners will be held in confidence, and will not be communicated in any form.

I accept and acknowledge that personal recording of any component of this session is strictly forbidden.

I am 18 years of age or older and have read this release before signing below, fully understanding the contents, meaning, and impact of this release.  I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

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