Url Permission & Release Form 2023 Complete a separate form for each participant Participant Name (print) * Permission to use name? * Yes No Organization: Healthy Futures of Texas Title of Film: * School: * Date * For good and valuable considerations, receipt of which I hereby acknowledge. I agree to the following (please check all that apply): * I am giving to Healthy Futures of Texas (named above) my original statements (or other works) I created ("Original Content"). I am giving to the Healthy Future of Texas (named above) permission to create photos, videotape, audio, other recordings, and transcriptions of me that may include my voice, likeness, name, and statements (“Authorized Recordings”). I represent and warrant that any Original Content that I have provided is my own original work, and is not subject to any rights of any other parties. I indemnify and hold Healthy Future of Texas harmless from any claims, actions, damages, or liabilities arising out of the breach of this representation and warranty. I grant Healthy Future of Texas an unconditional, irrevocable, royalty-free license to use, publish, reproduce, distribute, edit, and display the Original Content and/or Authorized Recordings in perpetuity, in whole or in part – or not to use it – in Healthy Future of Texas’s sole discretion, in any media, now known or hereafter invented, and for any purpose, including but not limited to advertising, promotions, research and fundraising purposes that promote Healthy Future of Texas’s mission (collectively, “Licensed Work”). This means, for instance, Healthy Future of Texas can broadcast video and audio podcasts of a recording of me on Healthy Future of Texas websites, other social media websites (such as YouTube.com, Instagram, etc.), or TV and radio. I understand I will not be able to review or approve the use of the Licensed Work, including alterations or derivative works, including adding my name to the Content if permitted above, which are strictly within the discretion of Healthy Future of Texas. I grant Healthy Future of Texas the right, without notice to me, to transfer or assign its rights under this Release to any third parties who may exercise the same rights (“Licensees”). I release Healthy Future of Texas, Licensees, and all people and entities associated with them of any and all liability to me and/or my property, including but not limited to any claims of defamation, privacy, or publicity, or claims of alleged misrepresentation of me, my character, or my person arising out of the Licensed Work and this Release. I grant this Release without any expectation of monetary or other compensation now or in the future. I warrant and represent that this Release does not in any way conflict with any existing commitment on my part. I certify that either (please check one below) * I am over 18 years of age and agree to the above. I am the parent or guardian of the minor participant named above and I agree to the above on behalf of the minor and myself. Signature of participant named above Signature of guardian (if participant is under 18 years old) Date Date Phone number of guardian Email of guardian 2300 W. Commerce Ave. Suite 212 San Antonio, Texas 78207
