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Photo/Video Release

In consideration of my engagement as a model, I hereby grant to The General Council of the Assemblies of God and its representatives and employees, the irrevocable right to take photographs and videos of me, and to make recordings of my voice, and to use these images and recordings, as well as my name and biographical information, as follows:

The use may include reproduction, distribution, modification, display, and performance.

The use may be in composite or modified forms and in any media, now known or later developed.

The use may be for any purpose throughout the world and in perpetuity.

I further acknowledge that I will not be compensated for these uses, and that the Assemblies of God exclusively owns all rights to the images and recordings. I waive the right to inspect or approve uses of the images and recordings. I hereby release the Assemblies of God, its representatives and employees, from any claims that may arise from these uses, including claims of defamation, invasion of privacy, or rights of publicity or copyright. This release is binding on me, my heirs, assigns, and estate.

I am 18 years of age or older and have read the above authorization and release prior to its execution. If under 18 years of age, the legal guardian indicated below has signed on my behalf.

Printed Elements: I my information to be available on printed elements.

Web Elements: I my information to be available on the U.S. Missions website. Please exclude the following information (e.g., phone number):

Media: I my information to be available on audio and video components.

Name:

Address:

Phone:

Email:

Department:
Chi Alpha

Website:

Leave this empty:

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Chi Alpha Campus Ministries https://chialpha.com

Timestamp

Audit

August 31, 2017 3:53 pm CDT

CMIT Application Signature- Information and Photo/Video Release of Model Uploaded by CMIT Program - cmit@ag.org IP 66.119.29.16

December 6, 2017 12:40 pm CDT

Document owner mlynch@ag.org has handed over this document to XAAffiliations@ag.org 2017-12-06 12:40:23 - 66.119.29.16

November 26, 2018 4:39 pm CDT

Document owner XAAffiliations@ag.org has handed over this document to cmit@ag.org 2018-11-26 16:39:25 - 66.119.29.16, 127.0.0.1