Image and Interview Release

For valuable consideration received, the undersigned hereby irrevocably consents to and
authorizes the use by Virginia Polytechnic Institute and State University ("Virginia Tech") of the undersigned's name, image, voice and/or likeness as follows: Virginia Tech shall have the right to publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or re-use the undersigned's name, image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed in perpetuity throughout the universe including advertising, promoting and merchandising the product or service. Virginia Tech may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or nonprofit.
Sign in to Google to save your progress. Learn more
Email *
Accepted and Agreed by (name):
Please indicate your agreement to the foregoing by checking below:
Clear selection
If the subject is under eighteen (18) years of age, subject’s parent or guardian indicate your agreement to the foregoing by checking below:
Clear selection
Parent/Guardian name:
On behalf of Minor Name:
Enter the child's name here
Teacher / Learner Group name:
School name, if applicable:
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Virginia Tech. Report Abuse