Tufts University Image Authorization Form PDF

TUFTS UNIVERSITY SCHOOL OF MEDICINE DOCTOR OF PHYSICAL THERAPY PROGRAM IMAGE AUTHORIZATION AND RELEASE I hereby grant to Tufts University School of Medicine and its students, agents and assigns (collectively referred to herein as “University”) the worldwide, pe...

TUFTS UNIVERSITY SCHOOL OF MEDICINE DOCTOR OF PHYSICAL THERAPY PROGRAM IMAGE AUTHORIZATION AND RELEASE I hereby grant to Tufts University School of Medicine and its students, agents and assigns (collectively referred to herein as “University”) the worldwide, perpetual, irrevocable right to: (1) photograph and prepare audio and video recordings of the undersigned; and (2) reproduce, distribute, display, create derivative works of and otherwise use the undersigned’s name, photograph and likeness and any such recordings for and in connection with the University’s educational, public relations, publicity, promotional, fundraising and recruitment purposes, for all but third-party commercial purposes, by any means, methods and media (print and electronic) now known or in the future developed that the University deems appropriate. I make this grant of rights with the understanding that no compensation will be paid to me by the University for such grant. I understand and agree that all right, title and interest, including copyrights, in the materials created by the University pursuant to this agreement are the exclusive property of the University and that I will obtain no rights in such materials. I also understand that the University is not actually required to use my photograph or likeness in any way. This agreement will be governed by the laws of The Commonwealth of Massachusetts and represents the final and exclusive agreement between the University and me on this subject. 9/29/24 Date:_________________ Verna Jayne zafra-Kasala Name:___________________________________________________________________ W. Jakart Signature:________________________________________________________________ P O Box 1123 Address:_____________________________________________________________________.. Agana, GU 96932 City/State/Zip:________________________________________________________________ ***** If the person named above is a minor, a parent or legal guardian must complete the following: I warrant that I am the legal guardian of the minor being photographed or whose likeness will appear in photograph(s) or other media as designated by the University and agree to the above. 119 Date:_________________________________ Maniaca Parent/Guardian Name:_____________________ Parent/Guardian Signature:___________________ Parent/Guardian Street Address: ___________________________________ Image Release