Seniors for Change program logo. links to main web page for this program

Hearts & Minds End Poverty Campaign logo links to more on how you can help END extreme hunger and poverty worldwideHearts & Minds - Information for ChangeSM

Seniors for ChangeSM - Creating inspiring art and making a difference

Release Authorization and Agreement to Hold Harmless

Back to Intro to Consent Form

This is an Agreement between Hearts and Minds Network, Inc. and all individual(s) specified below.

I, ______________________________, hereby give irrevocable, exclusive and unrestricted rights and full permission and authorization to Hearts and Minds Network Inc. ("Hearts & Minds") to use, re-use, copy, edit, alter, transform, distort, publish, license, assign and distribute words and images including photographs, audio and video recordings of me and my artwork, and spoken and written words (collectively called "the work"), done in any programs clearly sponsored by Hearts & Minds and/or the End Poverty Campaign.

This Agreement is for benefit of Hearts & Minds (a nonprofit, public service organization), its agents, licensees, representatives and assigns and shall be binding upon me and my heirs, legal representatives and assigns.

I understand that Hearts & Minds may decide in which media and in what manner the work will be published. The released artwork can be used for illustration, art, promotion, public relations, fundraising, advertising, trade, stock photography, promotion of any goods or services or any purpose whatsoever in any media now known or existing in the future.

Hearts & Minds shall be considered the author of the artwork under all copyright law of New York State and the USA and shall have ownership of the works. I release, discharge and agree to hold Hearts & Minds harmless resulting from any injury or accident, regardless of cause, from any liability arising out of this Agreement. Any dispute under this Agreement shall be decided by arbitration.

This Agreement can only be modified in writing and only when signed by both parties. I am at least 18 years of age* and have the legal right and authority to contract for this Agreement for myself.

I affirm that I have read carefully and have agreed to the terms in this Release Authorization.

Please print:

My full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Apt. #: |__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__| State: |__|__| Zip Code: |__|__|__|__|__|

E-Mail (optional): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|__|

Phone number(s): |__|__|__| - |__|__|__| - |__|__|__|__| and |__|__|__| - |__|__|__| - |__|__|__|__|

Signature: _______________________________________________

My age (not required if I am 18 or older)*: |__|__|   Date: ____/____/0__

If you do not want you or your participants to be identified by last name, place your initials here: |____|

Additional participant(s) (please print)*:

1. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

2. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age:|__|__|   Signature: _______________________________________________

3. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

*We refer to 18 years of age and wards because sometimes younger participants join in.

Feel free to Contact Us if you have any additional questions or concerns:

Hearts & Minds lightbulb logo links to home pageHearts & Minds

[email protected]

Intro to Consent Form  |  Main Page for this Section  |  Summary of the Program

Free Newsletter  |  Blog
Global Survival  |  End Poverty CampaignSM

Top of Page  |  Home Page  |   Site Guide
Contact  |  Join/Donate

This web page and entire website Copyright: 1997 - 2015 by Hearts and Minds Network, Inc. - online October 30, 2007, latest changes September 17, 2008