Template: Release Form for Use of Photograph/Video Recording
(fill in all of the bracketed areas as appropriate to your project, then delete
the brackets and these instructions)
[Project title]
Release Form for Use of Photograph/Video Recording
[Your name]
[Supervisor’s name if applicable (e.g., thesis advisor)]
Colorado College Department of [fill in department name]
[Phone number of department secretary, beginning with “719”]
[Your email address]
Please print:
Name of Participant: __________________________________________________
Address:
____________________________________________________________
I hereby give my permission to [your name] to use any photos
or video recording material taken of myself during [his or her] research on
[title of project]. The photos and videotape material will only be used for
research purposes and for the presentation of the research. [Describe how the
research will be presented.] I understand that [your name] has permission to
edit video footage or select photos as [he or she – whatever your sex is] sees
fit. I understand that my, name, likeness and other identifying information
will be incorporated as part of the research. As with all research consent, I
may at any time withdraw permission for photos or video footage of me to be
used in this research project. If I do not withdraw my permission, I understand
that my permission is given in perpetuity (without a concluding date). I
understand that I will not be compensated for the use of my likeness unless
agreed upon as part of the larger research project. [Provide the participant
with a copy of this form.]
Signature: ______________________________________ Date:
___________________
Comments
Post a Comment