FILM, VIDEOTAPE, AND/OR PHOTOGRAPH RELEASE FORM

CONSENT FOR THE RELEASE OF
NAME, IMAGE AND ART WORK
THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Name ________________________________________________________Date of Birth __________________
________________________________________________________________________
P.O. Box, Apt. No., Street
City
State
Zip
________________
Medical Rec# (if known)
I, the undersigned, do hereby irrevocably grant to the University of Mississippi Medical
Center, its officers, agents, employees, assigns and licensees, hereinafter called “UMMC,” the
absolute right and permission to record my likeness and/or voice with still photography, film,
videotape, and/or art work and to edit such still photographs, film, videotape, and art work, at
UMMC’s discretion, to incorporate the same into photo exhibits, motion picture films, video
presentations and other forms of art work, to use or authorize the use of still photographs, films,
videotapes, art work or any portion thereof, in any manner at any time or times throughout the world
in perpetuity, to copyright, use, re-use, publish, re-publish, exhibit, display, print, and re-print in
advertising, publicity or promotional material, magazines, books, or any other media, to use or
authorize the use of soundtrack recordings and records of me or my voice, including the right to
substitute the voice of another person or persons for my voice, and the right to use my name,
likeness, and biographical and other information concerning me in connection with the exhibition,
advertising, exploitation, promotion or any other use of such still photographs, films, videotapes,
and/or art work. I further agree to make any necessary assignment of any rights for this release or to
sign any other documents transferring rights in any recorded materials to UMMC if such rights
cannot be assigned.
I hereby waive any right to inspect and/or approve the still photographs, films, videotapes,
and/or art work or the editorial or printed matter that may be used in conjunction therewith and
further waive any claim that I may have with respect to the eventual use to which they may be
applied. Such still photographs, films, videotapes, and/or art work may be used at UMMC’s sole
discretion, with or without my name, alone or in conjunction with any other material of any kind or
nature. I hereby release, discharge, and agree to save harmless UMMC from any and all claims,
damages, liabilities, costs and expenses that I now have or may hereafter have by reason of any use
of the film, videotapes, photographs, and/or art work thereof.
I expressly agree that the foregoing release is intended to be as broad and inclusive as is
permitted by law of the State of Mississippi, and if any portion thereof is held invalid, it is agreed
that the balance shall, notwithstanding, continue in full legal force and effect. I further expressly
agree that any dispute regarding this agreement shall be resolved in the courts of __________ County
in the State of Mississippi and that Mississippi law shall apply.
I have read this release, fully understand its terms, and understand that I am giving up
substantial rights, including my rights to sue. I acknowledge that I am signing the release freely and
voluntarily, and intend by my signature to be complete and unconditional release of all liability to the
greatest extend allowed by law.
_________________________________________________
Signature or Personal Representative
______________________
Date
(Form must be completed before signing)
________________________________________________
Description of Personal Representative’s Authority
_________________________________________________
Witness
______________________
Date
________________________________________________________
Signature of University of Mississippi Medical Center Representative
______________________
Date