Authorization – Release of Information Video and/or Photograph Consent Form

Name *

First Last

Phone

Email *

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Student Type *

Traditional Residential
Adult Degree Program
DeVos Graduate School

Authorization of photographs, videos and recordings *

I authorize Northwood University, its agents, employees and contractors (collectively “Northwood”), as well as members of the media, to interview, photograph/video, and otherwise record me. I hereby grant to Northwood the worldwide, irrevocable, transferable and unrestricted right to use my name, image and likeness as photographed, videotaped, or otherwise recorded, and to publish, display, and distribute the recordings of me, or in which I may be included, for educational publications, electronic reproductions (websites) and/or promotional materials, including, for example, newspapers, magazines, television, billboards, digital efforts, exhibits, presentations, radio broadcasts and the like, or for any other purpose and in any manner or medium, without compensation. I further authorize Northwood to use my name and other information gathered from official records or provided by me for use in conjunction with any awards, honors, activities, or events for the purposes of publicity. I hereby release the photographer, videographer, Northwood and its contractors from all claims and liability relating to said recordings. Further, I waive any right, claim or interest that I may have in the recordings and waive any right or claim to future compensation. I acknowledge that any recordings taken of me will become and remain the sole property of Northwood or of the applicable media organization.

Acknowledgment of consent and understanding of terms *

I hereby acknowledge that I am 18 years of age or older and that I have read and understand the terms of this release.
I am under the age of 18

Acknowledgment of consent and understanding of terms *

I hereby acknowledge that I am 18 years of age or older and that I have read and understand the terms of this release.

If you are under the age of 18, you will be emailed a copy of this form that you will need to print and have signed by your parent/guardian, before returning it to the Office of Student Life.

Student signature

Parent/Guardian signature

Today's Date *

Phone

This field is for validation purposes and should be left unchanged.