Release Form (General/Under 18 Photo)

Van Andel Institute Photo/Video Authorization and Release Form

I hereby grant to Van Andel Institute and its supporting and/or related organizations such as, but not limited to, Van Andel Research Institute, Van Andel Institute for Education, Van Andel Institute Graduate School (collectively “VAI”) the worldwide, irrevocable, transferable and unrestricted right to use my name, image and likeness as photographed, videotaped, or otherwise recorded, and to publish, display, and distribute the photographs, video or other recordings of me, or in which I may be included, for corporate publications, electronic reproductions (web sites) and/or promotional materials or for any other purpose and in any manner or medium, without compensation. I hereby release the photographer, videographer, VAI and its contractors from all claims and liability relating to said photographs, video and recordings. Further, I waive any right, claim or interest that I may have in the recordings and waive any right or claim to future compensation.

I hereby acknowledge that I am 18 years of age or older and that I have read and understand the terms of this release.

For Participants under the age of 18, by my signature below, I attest that I am the parent or legal guardian of the Participant named below, and that I have the authority to execute this Release on behalf of the Participant and consent to this Release on behalf of Participant.

"*" indicates required fields

By signing below, Individual hereby executes this Authorization and Release as of Date:*

Please select the statement that best represents the Participant:*

I am over the age of 18 and am the Participant

I am the parent or legal guardian of the Participant

Participant's Name*

First Last

Printed Name of Parent/Guardian*

First Last

Email Address*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Signature*

Phone

This field is for validation purposes and should be left unchanged.