Name:
Date:
Event:
I hereby authorize The University of Texas of the Permian Basin, Office of University Communications, and those acting pursuant to its authority to:
(a) Record my likeness and voice on a video, audio, photographic, digital, electronic or, any other medium.
(b) Use my name in connection with these recordings.
(c) Use, reproduce, exhibit or distribute in any medium (e.g., print publications, video tapes, CD-ROM,
Internet/WWW) these recordings, in whole or in part, without restriction or limitations for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including educational, promotional or advertising efforts.
I release the University and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that I may revoke or withdraw this
consent at any time and such request must be submitted in writing to the University, Office of Communications.
I understand that all such recordings, in whatever medium, shall remain property of the University.
I HAVE READ AND FULLY UNDERSTAND THE TERMS OF THIS RELEASE.
Address: __________________________________________________________
Number Street City State Zip
Phone: __________________________________
(Area Code) Number
Signature: _________________________________________________________
Parent/Guardian Signature (if under 18): _________________________________
Date: _____________
This authorization is administered for the purpose of complying with the U. S. Department of Education regulation found
at 34 CFR Part 99, Family Educational Rights and Privacy Act (FERPA). Sec. 99.30 of the regulation addresses prior
consent required to disclose information contained within an education record. Any questions regarding this consent form
may be directed to the Office of Communications.