CARROLL COLLEGE

PHOTOGRAPH, SLIDE, AND VIDEO TAPE CONSENT FORM

I, __________________________________, hereby give  ______________________________ at Carroll College, Waukesha, Wisconsin permission to take and use photographs, slides, or video tapes taken of me, or in which I may appear, for teaching and/or research purposes.  I waive all rights that I may have to any claims for payment or royalties in connection  with any exhibition, televising, or publication of photographs or video tapes, regardless of whether such exhibiting, televising, publication or other showing is under philanthropic, commercial, institutional or private sponsorship and regardless of  whether a fee admission or film rental is charged. I release Carroll College and its officers, faculty members and agents from any liability in connection with the use of such materials.

LIMITATION

It is understood that the foregoing consent is subject to the following limitations:

A.  Under no circumstances will any such slide, photograph, or video tape contain my name.

B.         (Indicate any further limitation).

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Participant’s Signature: _____________________________________________

Date: __________________________________________________________

Name and signature of person authorized to consent for Participant*:

________________________________ Relationship ____________________

Date:__________________________

Witness’s Name: _________________________________________________

Witness’s Signature: _______________________________________________

Date: __________________________

Faculty Member’s Name: ____________________________________________

Faculty Member’s Signature: _________________________________________

Date: __________________________

* If participant is a minor or incompetent