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Photograph, Video, Name and/or Quotation Release Form

I, the undersigned, hereby give permission to Alberta Innovates-Technology Futures, Alberta Innovates-Bio Solutions, Alberta Innovates-Health Solutions, and Alberta Innovates-Energy and Environment Solutions (collectively “AI”) to use my material (photograph, video, name or quotation) without any further compensation to me. I understand this material will be used in communications and material by and about AI, its programs, services, sponsorship and joint ventures, and they will be distributed to the public through a variety of means, including, but not limited to, printed and electronic communications, social media, and promotional videos and publications. All communications by AI where this material will appear shall constitute the property of AI and the Government of Alberta, solely and completely.

I understand that the material may be used by or licensed to other public bodies, non-profit organizations and private companies for use in materials in promoting the province of Alberta generally and AI and its programs, services, sponsorships and joint ventures.

I waiver all moral rights, claims and objections arising from the use of this material, worldwide and in perpetuity, in favour of the Government of Alberta, AI, its agents, employees, partners and contractors.

My personal information is being collected under the authority of the Freedom of Information and Protection of Privacy Act and is subject to the provisions of that Act.  My consent allows for the collection, use and disclosure of my information for the purposes described above.  If I have questions regarding my consent or the use of my information, I can contact Rob Semeniuk at AITF at 250 Karl Clark Road, Edmonton, AB  T6N 1E4, telephone 780-450-5504, e-mail rob.semeniuk@albertainnovates.ca

I have consented to the use of my information, which is deemed to be personal information, only for the above-identified purposes.  I have the choice to provide my contact information if I wish to be contacted for future photos, videos, quotations or projects of this nature.

I understand that because my material will be available to the public in AI communications, it is not possible to consider an expiry date for this consent.  Cancellation of my consent may only limit the use of my information in future or new publications.

____________________________________ ____________________________________
Print name Signature

____________________________________ ____________________________________
Date (month, day, year) Witness (name and signature)

Contact Information (optional) ________________________________________________

________________________________________________

I am under 18 years of age. My parent or guardian has given consent for me to participate.

____________________________________ ____________________________________
Parent/Guardian Name (Please Print) Parent/Guardian Signature

Cancellation of Consent

I, _________________________________, cancel this permission. I understand that some action may have been taken prior to cancellation of this consent.

____________________________________ ____________________________________
Dated Signature

____________________________________
Witness
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