Multimedia Release Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@midmich.edu

Are you 18 years of age or older? If you are under 18, this form requires a parent signature.*

YesNo

Multimedia Release Statement

I hereby agree that the Board of Trustees of Mid Michigan College (the “College”), and those acting pursuant to its authority, shall have the right to record my participation, appearance, likeness and voice on videotape, audiotape, photograph, digital, electronic, or in any other medium and I hereby unconditionally and irrevocably consent to the College’s use of such materials for any legal purpose the College deems appropriate for the benefit of the College, including commercial and advertising purposes.

I also, hereby forever waive (i) any right to require payment or compensation from the College for the use of these materials by it or those acting pursuant to the College’s authority and (ii) the right to object to the use of such materials for any purpose permitted by this release, including, without limitation, the license or sale of such materials by the College and those acting pursuant to its authority who publish, print, display, exhibit, distribute, or otherwise publicly use any such materials for any legal purposes.

I understand that this release grants the College the right to edit, crop, retouch, or otherwise reasonably alter such materials, at its discretion, and, at its option, to reveal my name and identity in such materials or by descriptive text or commentary. I understand and agree that any intellectual property rights associated with such materials are the sole property of the College. Furthermore, I agree that this release shall be construed in accordance with the laws of the State of Michigan and if any term or provision of this release shall be held illegal, unenforceable, or in conflict with any law governing this release, the validity or enforceability of the remaining portions shall not in any way be affected or impaired thereby.

I agree to the above Multimedia Release Statement.*

Yes

Are you completing this form for a specific course?*

YesNo

Course Prefix

ENG, MAT, WLD for example.

Course Number

This is the number following the course prefix.

Section Number

This is the number following the course number.

Course Title

Introduction to Statistics, Humanities, Biology for example.

Instructor

Please include the instructor's first and last name.

Course Specific Release Statements

I understand that my course may be recorded for use in future semesters when this course is offered again, for faculty development, and in the current semester for students in different sections of the same course. For these purposes, I permit Mid Michigan College to release my education records that contain my voice or likeness when I am participating in this course, including asking questions, participating in a discussion or group work, and making presentations.

I authorize the release of work that I have created in the course listed above (e.g.,
PowerPoint slides when making a presentation, a video created for course-specific social media channels, etc.) for educational purposes. I understand that when appropriate, the instructor will redact my name from the assignment and that the instructor is prohibited from releasing grades associated with my work.

I understand that my consent is voluntary and not a condition or requirement of my participation in the course or my enrollment at Mid Michigan College.

I agree to the above Course Specific Release Statements.

Yes

If you do not agree with the above statement(s), contact a Mid Michigan College representative or your instructor and do not submit this form.

Signature*

Parent/Guardian Signature

Date*

MonthDayYear

If you've been asked to provide a multimedia asset (selfie, photo, video, audio file, etc.) you can upload it here.

Browse Files

You can use this tool to upload multiple files.

Significant effort has been made to ensure this content meets accessibility guidelines. If you encounter a barrier you can report the barrier at midmich.edu/reportaccessibilitybarrier or contact Strategic Communications at (989) 386-6622 x579 or stratcomm@midmich.edu.

In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, midmich.edu/securityreport.