MEDIA RELEASE FORM
Serendipity Sound
a division of "…of a different mind"
The undersigned agrees and consents to the filming, videotaping, or audio recording or other means of electronic, print or publication by Roger N. Meyer, dba Serendipity Sound.
I agree to the use of my image or voice for preparation of training, educational, or technical assistance materials to assist not for profit and private organizations concerned with disability and educational matters. I understand that income realized over and above the costs of recording, post-production, duplication, publication and distribution of these materials shall be returned to the organization or individual sponsoring the event being recorded to support administrative and other costs directly related to the operation and governance of activities described in the organization or individual's business plan and/or mission statement. I further agree that I shall expect no royalty payments, honoraria, appearance fees, nor shall I impose additional license or personal copyright conditions to the use of my image or voice, or that of my minor child(ren).
I reserve the right to preview any pre-publication use of my image, voice, or the image or voice of my minor child(ren). I further understand that I may withdraw my consent at any time, upon written notice, prior to publication, distribution, or re-release of any finished product. Once the media product is complete, I waive any further rights to withdraw consent and release.
This consent and release applies to the undersigned and the minor child or children identified below.
Date_____________________
Event___________________________________
Name of Persons Providing Consent and Release [print]____________________________
Signature______________________________________________________________
Full Name(s) of Minor Child(ren)
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