Consent to Release

Speaker Name*

First Name

Speaker Name:

Title of CE Program:*

Title of Educational Activity/Session:*

Date of Presentation*

Date

Do you give permission to CE Synergy, LLC. to share a copy of the handout created for this program (ie, PDF) with industry partners for their company’s internal use?*

YesNo

I consent to release the following elements of myself and my presentation to CE Synergy, LLC who will in turn use as indicated below. I understand no payment for this release will be issued. By signing this form, I grant CE Synergy, LLC permission to copy, display, and distribute my presentation (the “copyrighted work”) or my artwork for CE Synergy, LLC use in the following way(s): • I agree that my presentation and related handouts/materials, including personal photographs, images, or biographies, may be recorded and made available to activity participants via printed hard copies, .pdf files uploaded to flash drives, and/or mp3, mp4, and/or other video formats for use in the CE Synergy, LLC Learning Management System (LMS) or Web site. One or more of these distribution methods will be made available to all meeting attendees before, during, and/or up to 3 years after the activity and/or after posting. • I consent that CE Synergy, LLC may collect, store, and/or use the data and personal information related to my presentation as needed to develop and post the materials via CE Synergy, LLC LMS or Web site for the purpose of providing continuing education to healthcare professionals • I understand that it is my responsibility to be familiar with copyright laws in regard to my presentation. As the copyright owner, I retain all other rights to the copyright work, including without limitation, the right to copy, distribute, publish, display, or modify the copyrighted work, and to transfer, assign, or grant license of any such rights. I represent that I am the intellectual property rights owner for the copyright work and, as such, do not infringe upon, or misuse replication rights of any third-party materials. I agree, as an author/presenter, that if I am using copyrighted material, I will provide a copy of any/all permissions to copy documents obtained from the copyright holder; and this will be my or my institution's financial responsibility, unless otherwise agreed upon. • I understand that ACPE does not allow replication of an activity for presentation at another organization, association, or freestanding conference that is different from the first organization, unless there is a joint providership relationship or express permission is obtained. • I agree that this presentation will not be duplicated or reused for presentation at another conference, association, or organization without the express consent from CE Synergy.

Signature*

Date*