To be completed by interviewers, recording operators, and photographers.

I, ____________________________________, am a participant in the ___________________________ project for Centre College.  I understand that the purpose of this project is to collect audio and video recordings of ______________________, as well as selected related documentary materials such as photographs and documents, for inclusion in the permanent collection of Centre College.  These recordings and related materials serve as a record and as a scholarly and educational resource for Centre College and the general public.

I understand that Centre College plans to retain the product of my participation in _______________________, including but not limited to my interview, presentation, video, photographs, statements, name, images or likeness, voice and written materials as part of its permanent collection.

I hereby grant to Centre College ownership of the physical property comprising my collection.  Additionally, I herby grant to Centre College, at no cost, the perpetual, nonexclusive, transferable, worldwide right to use, reproduce, transmit, display, perform, prepare derivative works from, distribute, and authorize the redistribution of my materials in any medium.  By giving this permission, I understand that I retain any copyright and related rights that I may hold.

I hereby release Centre College, and its assignees and designees, from any and all claims and demands arising out of or in connection with the use of my materials, including, but not limited to any claims for copyright infringement, defamation, invasion of privacy, or right of publicity.

Should any part of my materials be found to include materials that Centre College deems inappropriate for retention with this project or for transfer to other collections, Centre College may dispose of such materials in accordance with its procedures for disposition of materials not needed for Centre College’s collection.

ACCEPTED AND AGREED

Signature __________________________________________________      Date____________________

Printed Name _______________________________________________    Date ____________________

Signature of Parent or Guardian (if interviewer is minor) _________________________ Date ___________

Printed Name of Parent or Guardian _________________________________________________________

Address________________________________________________________________________________

City _________________________________  State  _____________________________  Zip  ___________

Telephone (___) -   ______________

Partner organization affiliation (if any) __________________________________________________________________