Photo & Video Release Form I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded on audio, video, social media, or videotape without payment or any other consideration. I understand that in addition to my image, I authorize my presentation content to be edited, copied, exhibited, published and/or distributed and waive the right to inspect or approve. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. Photographic, audio or video recordings may be used for the following purposes: Conference website for educational purposes Social media Informational presentations such as a press release By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above, and that any items I've provided will never be available for purchase or resale. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Fax Please sign using your full name*By entering my full name below I acknowledge that I have read and agree to the terms and language stated in the above PHOTO & VIDEO RELEASE FORM. Today's Date* MM slash DD slash YYYY CAPTCHA