Media Release Form

Which Centre program or initiative are you taking part in?*
What is the name of the other Centre program or initiative that you are taking part in?*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date*
MM slash DD slash YYYY
Email*
Consent*
I agree to Canadian Roots Exchange use of my likeness in perpetuity.
I hereby grant Canadian Roots Exchange permission to use my recorded image, likeness and voice without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse settings within an unrestricted geographic area.

By agreeing to this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in a public setting.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of a Canadian Roots Exchange trip.

By agreeing to this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against Canadian Roots Exchange and its employees utilizing this material.
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