Media Release Form
Authorization, Consent, & Release:
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I hereby grant the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Network the irrevocable right and permission to use photographs and/or video recordings of me on IMPAACT Network and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.
I understand and agree such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain property of the IMPAACT Network.
I hereby release, acquit and forever discharge the IMPAACT Network, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
Name
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First Name
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Signature
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Date Signed
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Day
Year
Date
Study or program:
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Date of photo/video:
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Month
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Day
Year
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