Media Release Form - Kirov Academy of Washington D.C.

Kirov Academy Media Video / Photography Release Form

Full name of Kirov Academy Student*

First Last

Please enter the full name of the Kirov Academy Student to whom this Release Waiver applies.

Video / Photograph Release Waiver

I hereby grant Kirov Academy of Washington, D.C. the irrevocable right and permission to use photographs and/or video recordings of me on Kirov Academy and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Kirov Academy of Washington, D.C.

I hereby release, acquit and forever discharge the District of Columbia, the Kirov Academy, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.

Please indicate your permission as pertains to the Video/Photograph Release Waiver information outlined above.*

Yes, I agree with the Release Waiver and give permission.
No, I do not agree with the Release Waiver and do not give permission.

Is the individual being photographed or recorded under eighteen (18) years old?*

Yes, under 18 years old
No, over 18 years old

If the individual is under 18 years old then the parent/legal guardian needs to sign an additional section.

Signature of Parent/Guardian of Individual Photographed/Recorded*

I acknowledge that I am eighteen (18) years old or more and that I am the parent or guardian of the child named above.

I have read and I understand this document. I understand and agree that it is binding on me, my child (named above), our heirs, assigns and personal representatives.

Please type your Full Name as a Signature*

* I (We) confirm that we have read all provisions of this Video/Photograph Release Waiver and indicated my (Our) permission level. The electronic signature below and its related fields are treated by Kirov Academy of Washington, DC as a wet signature (ie. a physical, handwritten signature on a paper form).

Date of Signature*