Video/Photograph Release Form

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All individuals who participate in the making, creating, and on-camera presence must sign and submit this form. These guidelines are designed to provide rules and guidance to the American Dental Assistants Association (ADAA) members and other content generators on the process of submitting items for distribution to the ADAA’s YouTube channel.

Basic Contact Information

ADAA Number

Name

First

Middle

Last

Suffix

Attestations

*I hereby grant the American Dental Assistants Association the perpetual, irrevocable right and permission to use, display and distribute photographs and/or video recordings of me or created by me on YouTube or other media without compensation to me.

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*I understand and agree that such photographs and/or video recordings of me or created by me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings. I waive the right to approve the final product.

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*I hereby release, acquit and forever discharge the American Dental Assistants Association, its current and former trustees, agents, officers, members and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

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*I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name. This release is binding on me and my heirs, assigns and personal representatives.

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Acknowledgement

Name of individual to be Photographed/Recorded