HPTN Media Release Form

PHOTO/VIDEO RELEASE FORM

I give permission to the HIV Prevention Trials Network (HPTN), its partners and/or its funders to use my story, image, words, and/or voice for any purpose related to the work or business of the HPTN and its partners and/or funders, such as success stories for the HPTN website and social media platforms, brochures, exhibitions, and project reports.

SELECT TO ACKNOWLEDGE:*

I hereby grant the HIV Prevention Trials Network (HPTN) the irrevocable right and permission to use photographs and/or video recordings of me on HPTN 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 HPTN.I hereby release, acquit and forever discharge the HPTN, 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.

Photo Date & Time:*

MonthDayYearHourMinutesAM/PM Option

Print Name*

Please include your first and last name(s).

Signature*

Study, Program, or Activity:*

Example: HPTN Study Training

Your Email Address:*

example@example.com

For questions or concerns, contact the HPTN Communications Team via email: communications@hptn.org.

V3.0 | March 2023