Passport to GU-Q

Release and Assignment Form for the Use of Photographs, Video and/or Voice Recordings

I hereby authorize Georgetown University and those acting pursuant to its authority, including, without limitation, Georgetown University in Qatar, to videotape, audiotape, film, and/or photograph me or my child (if child is a minor) for use in education and/or research materials, news, releases, and/or promotional materials, in any and all media, as the University deems appropriate and necessary. I further authorize the copyright, reproduction, publication, sale, exhibition, broadcast, telecast, and/or electronic distribution of said material without limitation by the University.

I hereby release Georgetown University and those acting pursuant to its authority, including, without limitation Georgetown University in Qatar, from any claim, liability, or obligation whatsoever in connection with photography or other media in which I am depicted including any payment of royalties or other compensation.

Check one:

I do consent to the use of my name in connection with these materials.

I do not consent to the use of my name in connection with these materials.

Check one:

I do consent to the use of these materials for dissemination on the Internet as the University deems appropriate.

I do not consent to the use of these materials for dissemination on the Internet as the University deems appropriate.

Student Signature*

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Parent/Guardian Signature*

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