UC Berkeley Photographic Consent Form

The undersigned does hereby authorize

THE REGENTS OF THE UNIVERSITY OF CALIFORNIA

and/or its associates, assistants, or subcontractors to photograph/film

_____________________________________________.
Name (please print)

The undersigned authorizes The Regents of the University of California to permit the use and display of said photographs in any publication, multimedia production, display, advertisement or World-Wide Web Publication for the Library or its constituent departments.

The undersigned agrees that the Regents of The University of California may use name, likeness, or biographical information supplied by the undersigned.

The undersigned releases and forever discharges The Regents of the University of California, its agents, officers and employees from any and all claims and demands arising out of or in connection with the use of said photographs / images, including but not limited to, any claims for invasion of privacy or defamation.

Accepted and Agreed:

___________________________________________
Signature of Subject

____________________________________________
Signature of Witness

____________________________________________
Date

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I/we certify that I/we are the parent(s) or person(s) legally appointed the guardian(s) of the above signatory of this instrument, a minor person, and that the instrument hereinabove contained.

Executed this ____________ day of _________________, 2003, at _________________________

_________________________________________________________________________________
Signature of Parent/Guardian

_________________________________________________________________________________
Signature of Parent/Guardian