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Release Form
I, ______________________, hereby irrevocably consent to and authorize The Ohio State University, through [Department/Program Name/Faculty or Staff Name], other affiliates, licensees, successors and assignees (collectively, “University”), to photograph and videotape me, record my voice, conversation, sounds, images and likeness during and in connection with [project/course/conference name].
I hereby grant all rights to the University to use the results of such videotaping, photography, and recording, including my name and biographical information, in perpetuity, throughout the world. I understand that the University may duplicate and distribute this video or likeness in whole or part worldwide for research, educational, or non-commercial purposes.
I waive the right to receive any payment for signing this release and waive the right to receive any payment for the University’s use of any of the material described above or any of the purposes authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer generated scanned image and other electronic media.
[For use with student signees] In connection with the use of the material(s) as set forth above, I hereby waive the confidentiality provisions of the Federal Family Educational and Privacy Rights Act of 1974 with respect to the content of the material(s), including my name and status as a student at The Ohio State University.
I acknowledge that I have read and fully understood the contents of this document, and have freely signed below.

______________________________ ______________________________
Signature Printed Name

______________________________ ______________________________
Telephone Number Email Address

______________________________ ______________________________
Address Date







If release is provided on behalf of a minor:
I hereby certify that I am the parent or guardian of [student name], who is under the age of eighteen years, to whom this release applies and that I have the legal authority to execute this release. I approve the foregoing and agree that we both shall be bound thereby.

______________________________ ______________________________
Parent/Guardian Signature Parent/Guardian Printed Name

______________________________ ______________________________
Parent/Guardian Telephone Number Parent/Guardian Email Address

______________________________ ______________________________
Parent/Guardian Address Date

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