WVU Media Recording/Usage Release

WVU Media Recording/Usage Release
For the privilege of participating in activities for West Virginia University, I hereby give my consent form my image and likeness to be videotaped, audiotaped or photographed for the following uses:
Educational/instructional media

Recruitment/outreach media

Development media

Newsworthy media documentation

I further authorize West Virginia University and/or West Virginia University Hospitals Inc., and their component parts, to use this electronic media and/or photographs in any manner — whole or in part.This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographical reproductions thereof for the production of educational, instructional, promotional or institutional advancement materials which support the educational and outreach activities ofWest Virginia University.I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs and I release West Virginia University and its component parts from all liability which could result from its use.
Event name or purpose of photo or video*
Participant's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email *
jsample@company.com or jsample@mail.wvu.edu
Phone Number*
Home or cell phone
Signature

Clear
Date*

MonthDayYear
Date
A parent or guardian must sign this form if the model is a minor or if the model is hindered by mental or physical challenges.
Parent/Guardian's Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

WVU Media Recording/Usage Release

For the privilege of participating in activities for West Virginia University, I hereby give my consent form my image and likeness to be videotaped, audiotaped or photographed for the following uses: