MEDIA RELEASE CONSENT FORM

CONSENT, WAIVER, RELEASE AND LICENSE
First and Last Name (Printed):
Parent/Guardian (if under 18):
Address:
E-mail:
Phone:
Event/Location:
Date:
1. I, on behalf of myself and on behalf of any children or persons under my legal guardianship (collectively, the
“Undersigned”), hereby consent to the use of the Undersigned’s name, voice, likeness, image, performance,
appearance and other aspects of the Undersigned’s personality (collectively, the “Persona”) by Saskatchewan
Prevention Institute, and its directors, officers, employees, agents or associates (collectively, “SKPI”), howsoever
the same may be recorded, published, used, adapted, presented, or communicated by SKPI (collectively, the
“Works”) in association with the above-described event (the “Event”) and hereby grant SKPI the right to
reproduce, use, exhibit, broadcast, distribute and create derivative works of the Works in any media now known
or later developed as well as the Undersigned’s name for purposes which may include, among others,
promoting, publicizing or explaining SKPI, and for administrative, educational or research purposes.
The Undersigned acknowledge and agree that SKPI is the first owner of all copyright in and to the Works and
waives any and all world-wide rights, including, without limitation, all moral rights, the Undersigned may have
against SKPI as a result of any use of the Works by SKPI, and all ownership of, and world-wide copyrights and
other world-wide intellectual property rights the Undersigned may have in or to, any and all derivative works
created by SKPI using the Works.
The Undersigned waive any right to inspect or approve the use of the Works and acknowledge that SKPI will rely
on the within consents and waivers potentially at substantial cost to SKPI and the Undersigned hereby agree not
to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted
hereunder.
The Undersigned hereby release and forever discharge SKPI from and against all actions, claims, demands,
damages or liability whatsoever arising from or related to the use of the Works, including, without limitation,
any and all claims of defamation, invasion of privacy or actions, claims and demands seeking consideration from
SKPI for SKPI’s use of the Works.
2. With respect to any photographs, video or other recordings made by the Undersigned at the Event (the
“Undersigned’s Works”), the Undersigned hereby represent that: (i) the Undersigned’s Works were created by
the Undersigned; and (ii) the Undersigned owns and possesses all right, title and interest in and to the
Undersigned’s Works. The Undersigned hereby grant to SKPI an irrevocable, perpetual, royalty-free, worldwide, non-exclusive license to reproduce, use, exhibit and broadcast the Undersigned’s Works for purposes
which may include, among others, promoting, publicizing or explaining SKPI, and for administrative, educational
or research purposes.
3. The Undersigned hereby agree: (i) to execute such further and other documents and do such further and other
things as may be necessary to implement and carry out the intent hereof; (ii) that if any covenant or other
provision hereof is invalid, illegal or incapable of being enforced by reason of any rule of law or public policy,
then such covenant or provision will be severed from and will not affect any other provision contained herein,
and this instrument will be construed as if such invalid, illegal or unenforceable provision had never been
contained herein and all other provisions hereof will remain in full force and effect; (iii) that this instrument shall
be governed by and construed in accordance with the laws of the Province of Saskatchewan; and (iv) that this
instrument binds the heirs, executors, administrators and assigns of the Undersigned and is irrevocable by the
Undersigned or any of the foregoing.
THE UNDERSIGNED FURTHER ACKNOWLEDGE that he or she has read and fully understands the foregoing terms and
conditions prior to signing below this ____ day of __________________, 20___.
Signature of Witness
Signature
Signature of Witness
Signature of Parent/Guardian (if under age 18)
Respecting Your Privacy
The personal contact information you provide will not be published. It may be used to contact you to discuss
matters pertaining to the use of the Works and it may be shared with other SKPI employees for this purpose.