Photograph & Video Release Form

I hereby grant Dr. Jamie Marich/The Institute for Creative Mindfulness (“ICM”) permission to film, record and photograph me. I hereby irrevocably grant ICM the right to digitize, adapt, edit, display, broadcast, license and otherwise use my image, likeness and sound of my voice without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed, or may not be used at all. I waive the right to inspect or approve the finished product wherein my likeness appears. I understand that ICM owns all rights to the film, recording or photographs taken by ICM. I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photograph, audio or video recordings may be used for the following purposes:
- Web-based promotions/marketing
- Conference presentations
- Educational presentations or courses
- Informational presentations
- Online education courses
- Educational videos
By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. I hereby release any and all claims against any persons or organization utilizing ICM’s recordings or photographs for the purposes listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected during any ICM activity in which I participate.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby.
Full Legal Name*
First Name Middle Initial Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Signature*
By signing below, I express my understanding and intent to enter into this Release willingly and voluntarily.
Date*
MM slash DD slash YYYY
Are you under the age of 18?*
- Yes
- No
Parent/Guardian Signature*
If this release is obtained from a presenter under the age of 19, then the signature of that presenter’s parent or legal guardian is also required.
Date*
MM slash DD slash YYYY

Photograph & Video Release Form

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