Video Image Release Form for Without Words, a project by Eudora Welty, supervised by Rosalind Franklin.

USAGE:  Without Words is a film and/or video project.  The resulting product will be a film and/or video, Internet web pages, stills for publication, promotional materials, distribution materials, art installation, or other creative work that will be available to the public.

I, the undersigned participant, hereby give Eudora Welty and Rosalind Franklin specific permission to publish, copyright, distribute and/or display images (motion and still) of my likeness created as part of the Without Words project.

By signing below, I acknowledge that 1) I have read this agreement carefully; 2) any questions I have about the use of my image have been answered satisfactorily; 3) any additional assurances or verbal qualifications that have been made to me have been added in writing to this document; 4) I have been given a copy of this form, including any changes or restrictions, initialed by me and by Eudora Welty.

I understand and agree to the conditions outlined in this video image release form.  I hereby allow Eudora Welty and Rosalind Franklin to use this recording, and I give up any and all of my own future claims and rights to the use of this recording.

Participant’s signature:  ______________________________

Date:  _________________

Participant contact information (optional):  ________________________________

Filmmaker’s Contact Info:  Eudora Welty; Bard College, 845.758.xxxx.

Rosalind Franklin, Ph.D., Film Program; Bard College, 845.758.xxxx.