#BIRTHBACK Photo Contest
Please fill in the form below and upload your photos to submit your entry to the contest. Contest details are available at https://bit.ly/49uYjCe
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preference regarding the use of your name in association with your photos?
I consent to the use of my full name
I consent to the use of my first name only
I consent to the use of my photographs anonymously
Consent Agreement
Please read and check all the boxes below to grant NCIM and CAM permission to use your photographs. You may choose not to consent, in which case we will not use your photographs and they will not be entered into the contest.
I hereby grant permission to the National Council of Indigenous Midwives (NCIM) and the Canadian Association of Midwives (CAM) to use the photographs I submit today in any and all of its publications, including but not limited to, website entries, social media posts, educational and promotional materials.
I hereby irrevocably authorize NCIM and CAM to edit, alter, copy, exhibit, publish, or distribute these photographs for purposes of promoting Indigenous midwifery. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears.
I understand that if my photographs are selected by NCIM I will receive an honorarium of $100 CAD per individual photo selected. Upon receipt of said honorarium, I waive any right to royalties or other compensation arising or related to the use of the photographs. I understand that photos which are not selected will not receive an honorarium and will not be used by CAM or NCIM.
I have the right to withdraw my consent at any time. If I choose to withdraw my consent, I will notify NCIM in writing, and my photos will no longer be used for promotional and marketing purposes.
I release NCIM and CAM, its employees, contractors, and representatives from any liability arising out of the use of my photos for educational, promotional and marketing purposes.
I am at least 18 years of age and competent to sign this release form. If the model/subject is a minor, I am the parent or legal guardian of the minor and have the legal authority to execute this release on their behalf.
Signature
Date
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-
Day
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Photo Submission
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