Teach MEDisability: Photo Submission Form

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Hello!

Thank you so much for taking the time to fill out this form and submit a photo here.

This survey is a photo release form. That means that by filling this out, you're saying that it is okay for the University of Colorado to use the photo that you upload here for various purposes. For this project, the photos will be used by professors in their lectures when they are teaching about a given disability. People who use the photo will see the photo and the name of your condition/disability, and that's all.

Please take the time to read the form carefully and fill it out.

If you would like to keep up with Teach MEDisability and know if we open it up for use by other medical schools or publish a paper based on our findings, please enter your email.

Again, thank you for your help with this project!

By signing this Photo, Video and Sound Recording Release and Consent Form, you are irrevocably giving permission to the Regents of the University of Colorado and the University's officers, agents, employees, successors, licensees, and assigns to take and use photographs, video or sound recordings of you for the following project: Teach MEDisability. This is completely voluntary and up to you.

Your consent to the use of the photographs, video and sound recordings and your image, likeness, appearance, and voice is for forever. You will not receive compensation for the use of your image, likeness, appearance, and voice now or in the future. The University may use the photographs, video and sound recordings containing your image, likeness, appearance and voice in any manner or media, including use on web pages. The photographs, video and sound recordings may be used in whole or in part, alone or with other recordings. The photographs, video and sound recordings may be used for any educational, institutional, scientific or informational purposes whatsoever, including to promote the University, but not for any commercial uses. The University has the right and may allow others outside the University to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at the University's discretion. All right, title, and interest in the photographs, video and sound recordings belong solely to the Regents of the University of Colorado.

You further give permission to the University to use your name, biography, and any other personal data, events, or other material in or in connection with any such uses of the photographs, video and sound recordings.

I understand and agree to the conditions outlined in this photograph, video and sound recording release and consent form. I irrevocably give consent to the Regents of the University of Colorado and the University's officers, agents, employees, successors, licensees, and assigns forever to make use of my image, likeness, appearance, and voice in photographs, video and sound recordings as described above. I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this instrument.

Printed Name of Participant:

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Signature of Participant:

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Date:

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M-D-Y

Relationship to person in photo(s):

Parent/guardian

Other

Self

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If you selected 'other' above, please explain:

How many photos are you submitting to the project?

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