Photo and Video Consent, Assignment and Release Form

Purposes: For marketing, advertising, promotional and/or communication purposes, the YMCA and/or EarlyON Operators working as part of EarlyON Operations in the Regional Municipality of Waterloo or the City of Stratford, may, from time to time, take photographs and/or video recordings of EarlyON based activities or events that include real people, which photographs and video recordings will be placed in the YMCA National Photo Bank and which may be used by the YMCA in Canada and elsewhere in the world, for its own informational, promotional or advertizing purposes, and by any other person authorized by the YMCA (an "Authorized Third Party") to use such photo or video recordings, in any part of the world, in connection with such Authorized Third Party's support for, association with, or arrangements with, YMCA (collectively, as the "Purposes"). For purposes of this Form, "YMCA" refers to YMCAs and YMCA-YWCAs in Canada or elsewhere in the world (as part of the World Alliance of YMCAs) and to YMCA Canada, and the World Alliance of YMCAs.

You understand that by signing this Form, you are consenting to the taking of photographs and/or video recordings of myself and my child/ren, whose name(s) is/are listed below, by the YMCA and/or EarlyON Operator for the purposes, you are assigning to the YMCA, and waiving any rights you have related to any such photographs and/or video recordings, and you are consenting to the use of any such photographs and/or video recordings, in whole or in part, by the YMCA and any Authorized Third Party for the Purposes.

Any inconsistency between this Form as expressed in English and any other language shall, to the full extent permitted by applicable law, be resolved by reference to the English version. By signing my name, I (and my legal guardian, where applicable) acknowledge that I (or we) have carefully read and understand this Form.

Date

My Name*

First NameLast Name

My Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My Phone Number*

Area CodePhone Number

For valuable consideration received but without any promise of remuneration, I hereby agree to allow photographs and/or video recordings to be taken of me, whether posed or candid, while I am on YMCA property and/or participating in YMCA activities or events, including and not limited to events related to EarlyON Child and Family Centre operations to be reproduced, published, displayed, broadcast, transmitted, licensed, sublicensed or otherwise used by the YMCA or any Authorized Third Party in connection with the Purposes, including without limitation on YMCA internet web sites, in YMCA printed materials, or in any other materials or medium whatsoever and wherever (the “Work Product”). I confirm that neither the YMCA nor any Authorized Third Party shall be obligated to use the Work Product..*

YesNo

I understand that the Work Product is being created under the direction and control of the YMCA. I hereby irrevocably assign to the YMCA any and all rights, including copyright, financial or other rights, and I hereby irrevocably waive in favour of YMCA and any Authorized Third Party any and all moral rights or rights of similar nature that I may have in the Work Product. I agree that the YMCA has the sole worldwide ownership and rights in and to the Work Product, including copyright interests, and I acknowledge that I have no interest or ownership in the Work Product or its copyright. To acknowledge check "Yes".*

YesNo

I agree that I will not bring or consent to others bringing a claim or action against the YMCA on the grounds that anything contained in the Work Product, or in the manner in which the Work Product is used, is defamatory, reflects adversely on me, or violates any other right whatsoever, including, rights of privacy and publicity. I hereby release and forever discharge each of the YMCAs, any Authorized Third Party and their respective officers, directors, employees, agents, partners and affiliates, and their respective heirs, executors, personal legal representatives, successors and assigns, as applicable, from all actions, claims, causes of action, suits, demands, liabilities and damages whatsoever, in law or equity, which I may have against any of them in connection with the Work Product. To acknowledge check "Yes"*

YesNo

By checking "yes" below, I confirm that I am over the age of majority in my province or territory of residence and am competent to execute this Form and to participate in the development of the Work Product; or, to the extent that I am under the age of majority in my province or territory of residence, have had my parent or guardian review this Form and consent to my participation in the creation of the Work Product on my behalf.*

YesNo

Are you the parent or legal guardian of a child(ren) that you are signing this release on behalf of?*

YesNo