Medical History/Emergency Contact
Media Release Form
Open Media Release Form
In order to document and share educational practices with graduate students, the broader education community, and the general public, Triple Direct Leadership, LLC produces educational, instructional, public relations, and marketing materials, such as, without limitation, curricular materials, instructional video, websites, brochures, annual reports, newsletters, press releases, and other items. Triple Direct Leadership, LLC will record and describe through audio, video, photography, print, and other means (“Recordings”), classroom instruction and other educational activities, and may broadcast, license, publish, or post all or part of such Recordings. I, the undersigned, hereby consent to being included in Recordings made by Triple Direct Leadership, LLC or others authorized by them and to the broadcasting, licensing, publishing, posting, or other lawful use of Recordings in which I am featured, in whole or in part, and hereby grant any rights in connection with the use of such Recordings, which may include but not be limited to my name, image, likeness, spoken words, teacher work (including any copyright(s) therein), performance, and movement, in any and all forms of media. I acknowledge and understand that I have no control over how Triple Direct Leadership, LLC or others authorized will use the Recordings, how such Recordings will be edited, or how I will be portrayed. I waive any right to inspect or approve Recordings that may be used now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the Recordings. I acknowledge and understand that Triple Direct Leadership, LLC shall own all rights, title, and interest, including the copyright(s), and I hereby irrevocably grant and assign all such rights I may have in and to the Recordings, to be used and disposed in perpetuity without limitations at Triple Direct Leadership, LLC’s sole discretion. By entering into this informed consent and release and granting the permission as stated herein, I release Triple Direct Leadership, LLC and others authorized and each organization's or authorized person's respective affiliates, officers, directors, agents, assigns, licensees, successors, and/or employees from and against any and all liability, loss, damage, costs, claims (including but not limited to claims for invasion of privacy or defamation), and/or causes of action arising out of or related to my participation in any media events, including but not limited to, television broadcasts, promotional materials, and website projects. I have fully read this Release and Consent and understand its terms, contents, meaning and impact. I sign this voluntarily and with full knowledge of its significance.
I wish to have access to the media for personal use as well.
I asknowledge this Media Release and its contents in Full
Triple Direct Leadership, LLC
EXPERIENCE, ADVENTURE, GROWTH Se Habla Español