SHARE YOUR OPIOID STORY
Consent, License and Release Agreement
By submitting my story and any other files to the website www.shareyouropioidstory.com, I, the undersigned, hereby consent to voluntary participation in the outreach program entitled “Share Your Opioid Story: A Collaboration between Independence Blue Cross Foundation, The Department of Drug and Alcohol Programs, and Penn State University”, which I understand will include photography, video recording, and audio recording of me. I hereby grant my permission and consent to The Pennsylvania State University (“Penn State”) and its affiliates, officers, agents, and employees (together, “Penn State Representatives”) to photograph, video record, or audio record me.
I hereby grant an irrevocable, sublicensable, world-wide, royalty-free right and license to Penn State and Penn State Representatives to use, exploit, adapt, modify, reproduce, distribute, publicly perform and display the photographs, video, and/or audio (collectively “Media”) taken of me for use in promotional, educational, informational, advertising or commercial materials and communications in any from now known or later developed, including but not limited to publications, websites, articles, brochures, books, magazines, newsletters, exhibits, videos, films, social media, advertisements, and training programs (collectively “Materials”). Furthermore, I hereby authorize and consent to the use of my name, image, likeness, and voice (collectively, “Likeness”) in the Media for all Materials or any other purposes deemed appropriate by Penn State.
I hereby waive any right to be notified or to inspect or approve the Media or any Materials that are created using my Likeness, now or in the future, whether that use is known or unknown to me. I hereby waive any right to royalties or other compensation arising from or related to the use of the Media or Materials. I hereby release and hereby agree to indemnify and hold harmless Penn State and its trustees, Penn State Representatives, and their licensees and assigns for any and all claims that I or any third party may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation, or any other cause of action arising of the use, exploitation, adaptation, modification, reproduction, distribution, publicly performance or display of my Likeness in the Media or Materials. In accordance with this complete release of all rights in my Likeness used in the Media and Materials, I hereby waive any and all claims, damages, or liability arising from or related to the use of the Media, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, of my Likeness that may occur or be produced in taking, processing, reducing, adapting, modifying, producing, reproducing of the Media and Materials and their publication, distribution, display or performance.
I understand and agree that Penn State is and shall be the exclusive owner of all right title and interest, including any copyright, in the Media and Materials.
Through my online submission, I am confirming that I have read this Consent, License and Release, and I fully understand the contents, meaning, and impact of this Consent, License and Release. This Consent, License and Release shall be binding upon and inure to the benefit of my successors and assigns, and contains the entire understanding of the parties with regards to the Media and Materials.
I hereby represent that I am eighteen (18) years of age or older and I am competent to contract in my own name.