FIRST NATIONS HEALTH COUNCIL Implementing the First Nations Health Plan on behalf of BC First Nations
1205–100 Park Royal South West Vancouver, BC, V7T 1A2 Toll-free: 1.866.913.0033 Telephone: (604) 913.2080 Facsimile: (604) 913.2081
ADULT RELEASE FORM Individual Name: Location of Photography/Recording: Dates of Photography/Recording: In consideration of good and valuable consideration (the receipt and sufficiency of which is hereby acknowledged) including possible publicity, and without further consideration, the undersigned hereby authorizes FIRST NATIONS HEALTH COUNCIL (“FNHC”), its employees, contractors, agents and representatives, to record my picture and voice on photographs, films, audio and videotapes or digital recording media and further grants to FNHC, all rights of every kind, whether now known or coming known, in and to all photographs and other recordings (the “Recordings”) made by FNHC of my likeness, poses, acts, performances, appearances or voice, including, without limitation, the right to use the Recordings and my name (or any fictional name provided) in all forms and all media (including, without limitation, videos, printed materials, public display and exhibition, publish in book form and electronic reproduction and dissemination) throughout the world in perpetuity including for purposes of publicity and promotion. I waive any right to approve the Recordings or any finished works in which they are used or reproduced. I further grant my consent and full right to utilize the content or product of any interview of me, in whole or in part, with or without credit to me, in any and all media, and in any advertising and publicity in connection with any work utilizing the product of such interview, with the unlimited right to reveal fully, quote directly, paraphrase, edit, rewrite, or otherwise make use of the product of such interviews. I hereby agree that I shall have no right (including, without limitation, copyright), title or interest in or to the Recordings, product of interviews or any work in which they are used or reproduced. I expressly release FNHC, its employees, contractors, agents, representatives, licensees, successors and assigns from and against any and all claims which I have or may have for invasion of privacy, defamation or any other cause of action arising out of the making of the Recordings and their use. This Release is given for the benefit of FNHC and for the benefit of its successors, licensees and assigns and is fully assignable by FNHC. I represent that I am of full age of majority. I have read this release and fully understand its contents.
Signature: Print Name: Address: Date: