Film & Media Consent Form

I hereby give consent to
I hereby give my consent to the FIU School of Music and The Florida International University Board of Trustees ("FIU"): (a) to record my likeness and voice/instrument/performance on a video, audio, photographic, digital, electronic or any other medium and to use my name in connection with these recordings; and (b) to use, reproduce, exhibit or distribute these recordings in whole or in part in perpetuity in any and all media throughout the universe (including but not limited to print publications, video tapes, non-theatrical, home video, CD-ROM, internet and any other electronic or other medium presently in existence or invented in the future) for any purpose that FIU, and those acting pursuant to its authority, deem appropriate, including promotional, recruiting, advertising and any commercial or non-commercial use. I hereby release the FIU School of Music, Broadcast Video and Production and FIU from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I may hereafter have in connection with such use of my likeness, voice, instrument, or performance or name in any medium. I understand and agree that all such recordings in whatever medium, shall remain the property of FIU. I have read and fully understand the terms of this release.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
Name Name First Last
Panther ID
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####