Multimedia Authorization and Release Form

If you prefer, you can complete this form as a document.
Download the Multimedia Authorization and Release Form (PDF)

The University of Kansas ("KU") publicizes and promotes its activities in various media formats for general educational use and for the general public in the areas of research, patient care, and service. To accomplish this goal, KU requests persons to authorize KU to record and to use their name, likeness, voice, and/or performance by any means of recording, including, without limitation, photography, video recording, and/or quoted statements.

In the interest of furthering the above purpose, the undersigned agrees as follows:

1. To authorize KU to record my name, likeness, voice, and/or performance by any means of recording, including, without limitation, photography, video recording, and/or quoted statements, made as a result of:

* must provide value

Expand

2. To authorize KU to use my name, likeness, voice, and/or performance by any means of publication, including, without limitation, publication in the form of published media articles, videos, newsletters, brochures, websites, and social media channels owned or operated by KU or a media outlet;

3. To not receive any consideration, including, without limitation, royalties and/or payments from KU or its related entities for such recordings and use by KU of my name, likeness, voice, and/or performance in any publication;

4. KU has all rights, title, and interest to, and the undersigned herby assigns to KU any rights of the undersigned to any recording and any use of the recording made pursuant to this form, and KU is authorized to control distribution, editing, and use of such recording; and

5. To release and hold harmless KU, KU's related entities, and their agents, personnel, trustees, directors, officers, and employees against any and all claims for loss, damages, or injuries as a result of participating in the activities anticipated by this form, including, without limitation, the recording, use, and publication of the name, likeness, voice, and/or performance of the undersigned.

First Name

* must provide value

Last Name

* must provide value

Address

* must provide value

Phone number

* must provide value

Date of Release

* must provide value

M-D-Y

Signature

* must provide value

Add signature

If completing on behalf of a minor:

Parent/Guardian Name

Relationship to Minor

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.