AGE+ Media Release Form

I grant permission to AGE+ and its partners to use my name, photographs and video for use in AGE+ publications such as brochures, newsletters, and magazines, and to use my name, photographs and video on display boards, and to use my name and/or photographs in electronic versions of the same publications or on the AGE+ website or other electronic forms or media. I also allow my name and/or photographs to be used for educational purposes and publications. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless AGE+ and its partners, including universities or any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

Please check the option below that is applicable to your present situation.