MEDIA RELEASE FORM

I hereby give my consent for the image and likeness of ________________________________

to be interviewed, videotaped, audiotaped, or photographed for the following uses:

• Educational/Instructional media • Recruitment/Outreach media

• Development media • Newsworthy media documentation

I further authorize Spring Arbor University to use this electronic media and/or photographs in any manner.

This waiver includes usage of this media in any way deemed appropriate, which may include

electronic and photographical reproductions thereof for the production educational, instructional,

promotional, or institutional advancement materials which support the educational and outreach

activities of Spring Arbor University.

I hereby waive any right I may have to inspect or approve any use of this electronic media and/or

photographs and I release Spring Arbor University from all liability which could result from its use.

Participant’s Name: ___________________________________________________________________

Address: _____________________________________________________________________________

_____________________________________________________________________________________

Telephone: (___) ____________________ E-mail: ___________________________________________

Participant’s Signature: ________________________________________________________________

(Required)

A parent or guardian must sign this form if the participant is a minor or if the participant is hindered

by mental or physical challenges.

Parent/Guardian’s Name (please print): ___________________________________________________

Parent/Guardian Signature: _____________________________________________________________

(Required)

Please retain a copy of this media release in your office records.

AUTHORIZATION.

I grant Spring Arbor University (hereafter “SAU”) and those acting under its authority the nonexclusive right to use and publish video and sound recordings (for use as a podcast, etc.) of me and the other presenters in my speaking/program session for which I retain the copyright. I further grant SAU and those acting under its authority the nonexclusive right to use and publish written program materials prepared by me, conference CD, DVD, photos or other digital media on the SAU Web site, for which I retain the copyright.

Description of activities involved: Video and audio taping of all sessions, workshops, speeches, pre-conference sessions and related activities taking place at or for SAU.

SAU GUIDING PRINCIPLES: As a presenter for Spring Arbor University, I understand and recognize the guiding principles of SAU as described below in the University’s mission statement known as the Concept.

Spring Arbor University is a community of learners distinguished by our lifelong involvement in the study and application of the liberal arts, total commitment to Jesus Christ as the perspective for learning and critical participation in the contemporary world.

____________________________ ____________________________

Participant Signature Date

____________________________ ____________________________

Signature of Department Representative Date