Smith-Kettlewell Media Consent

I, the undersigned, hereby grant permission to The Smith-Kettlewell Eye Research Institute (“Producer”) to record video, photographs, sound, speeches, interviews and appearances of me and to distribute or exhibit the same in whole or in part, in any medium and for any purpose whatsoever, including promotion and advertising. I understand that Producer’s records of me will be maintained and made available indefinitely by Producer for such research, production (World Wide Web, exhibitions, related advertisements, radio, television, DVDs, promotional reel … ), and educational purposes as Producer shall determine. I hereby grant, and transfer to Producer all rights, title, and interest in any interview, conference presentation, and video documentary as well as the right to use my name in connection herewith if it so chooses. I hereby release and discharge Producer from any and all claims and demands arising out of or in connection with the use of the audio-video footage, including any and all claims for libel and allow it to copyright the same in Producer’s name or any other name that it may choose. I am over the age of eighteen. I have read the foregoing and fully understand the contents thereof.