Template: Release Form for Use of Photograph/Video Recording (fill in all of the bracketed areas as appropriate to your project, then delete the brackets and these instructions)

[Project title]

Release Form for Use of Photograph/Video Recording

[Your name]

[Supervisor’s name if applicable (e.g., thesis advisor)]

Colorado College Department of [fill in department name]

[Phone number of department secretary, beginning with “719”]

[Your email address]

Please print:

Name of Participant: __________________________________________________

Address: ____________________________________________________________

I hereby give my permission to [your name] to use any photos or video recording material taken of myself during [his or her] research on [title of project]. The photos and videotape material will only be used for research purposes and for the presentation of the research. [Describe how the research will be presented.] I understand that [your name] has permission to edit video footage or select photos as [he or she – whatever your sex is] sees fit. I understand that my, name, likeness and other identifying information will be incorporated as part of the research. As with all research consent, I may at any time withdraw permission for photos or video footage of me to be used in this research project. If I do not withdraw my permission, I understand that my permission is given in perpetuity (without a concluding date). I understand that I will not be compensated for the use of my likeness unless agreed upon as part of the larger research project. [Provide the participant with a copy of this form.]

Signature: ______________________________________ Date: ___________________

see more: Video Release Form