Release and Consent Form Participant Information First Name: Last Name: Phone Number: Email Address: Date of Birth: Are you 18 years of age of older? Yes No If under 18, parent or legal guardian consent is required. Before submitting this completed form, Please screen capture (print screen) the completed Release and Consent form. Print the screen capture and have parent or legal guardian sign the completed form. Email signed form to the Marketing and Communications team. Are you currently enrolled at Seminole State College? Yes No Please enter your Student ID: Release and Consent BY CHECKING THIS BOX, I hereby authorize Seminole State College of Florida, its Board of Trustees or employees to photograph, record, tape, film or electronically capture in permanent form my name, likeness, image, voice, appearance and performance. I understand that I am under no obligation to provide this consent and am doing so voluntarily and of my own free will. I consent to and grant full permission to Seminole State for the use of my name, likeness, image, voice, appearance and performance without remuneration to me in whole or part, for educational and instructional purposes only (to include advertising, promotion and public relations), in print, tape, audio, visual, open broadcast, cable, closed-circuit exhibit, computer link, or any other format or media now known or hereinafter devised worldwide in perpetuity. BY CHECKING THIS BOX, I further acknowledge and grant full permission for Seminole State to alter, modify, edit, reproduce, display, distribute, exhibit, combine with other materials and otherwise use at its discretion any of the above-described materials. BY CHECKING THIS BOX, I also release Seminole State from any and all claims that may arise out of the use of any image or recording of any of the above-described materials, including, but not limited to invasion of privacy, misappropriation of image or likeness, libel, slander, false rights or any other cause of action arising out of the taking, recording or use of any of the above-described materials. Student Name: Date: *Parent/Legal Guardian signature: *Parent/Legal Guardian Signature Date: * Parent/Legal Guardian signature and date are only required if you are under the age of 18. Submit
Marketing and Communications