Video Informed Consent Form

VIDEO CO NSENT FORM (the “Form”)
SBA Visa Export Video Contest (the “Contest”)
Instructions for Video Submitter:
Anyone that appears in the Video must complete and sign this Form. If a minor appears in the Video, the minor’s parent/legal
guardian must also sign this Form. Print this form and ensure it is completed by hand. Scan the form and combine all scanned forms
into one single file (ZIP, PDF, or doc).
A Submission (as d e fined in the Contest’ s Offic ial Rules) will not be final until the U.S. Small Business Administration (SBA) and Visa
U.S.A, Inc. (Visa), collectively the “Cosponsors”, receive a completed form(s) for each individual that appears in the Video. The
completed Form must be uploaded as part of a Submission.
Information of Individual appearing in t he Vi deo
(required):
Name: _______________________________
Phone Number:_________________________
Parent or Legal Guardian’s Information (required if
the individ ual is a minor ) :
Name: _______________________________
Address: _______________________________
Phone Number:__________________________
Relationship to Minor:_____________________
I represent and warrant that:
1. I have read , understood and agree to the Contes t’s Official Rules located at [I NSERT URL] (the “Rule s”);
2. I understand that I am pro vi ding cert ain ri ghts to the C osponsors in connection with the Vid eo, inc ludi ng, but no t
limited to
a. grantin g to t he Co sponsors and other acting on their behalf, a perpetual, irrevocable, royalty-free nonexcl usive
worldwide licen se to copy, distribute, modify, display a nd perform publicly and otherwise use, and authorize
others to use, the Submission fo r any educational purpose thr oughout the world and in any media, and license
others to do the same, the Submission, for the purpose of the Contest, i ncludi ng posti ng or lin king t o the
Sub mission on the Cosponsors’ websites and social media pages and ma king it available to the general p ublic
from it s r e sp e c tive web site s and soc ia l media pa ges and to distribute it to group s and a ny other organizatio ns
interested in showing it for e ducational purposes, includ ing, but not limited to, Internet site s, c onference s and
events, on television, and o ther media outlets; and
b. the right and permissio n to record, copy, reproduce, adapt, edit, summarize, publish, e xhibit, distribute and
otherwise exploit b y any and all uses and media, now known or hereafter de vised, t hro ughout the uni vers e unti l
one year after the announceme nt of winners (collectively, “Use”), my or my minor individual’s appearance,
name, likeness, and voice in any manner, format or context whatsoever (collectively, the “Materials”). Said
grant shal l i nclude, without limitation, the right fo r the Cos ponsors a nd those act ing o n behalf of the C ospons or s
to use the Mater ials in and in connec tion with the Contest, i n any other video, film or te levision pro gram, in
print, e le c tronic and o r photo /e ssay materials and public a tion, a nd in all types of advertising and p romo tion
relating to the Co ntest.
3. I hereby waive any right to inspect or approve Materials or the Use to which such Materials may be applied.
I release, discharge, and hold harmless the Cosponsors from and against any and all clai ms that I (and the minor)
may have ari sing from or in connect i on with my partici pa t ion in the Submissi on and its related e vents. I furthe r
agree to indemnify, defend, and hold the Cosponsors harmless against any and all losses, claims, and expenses
(i ncluding reasonable a tto rney s ’ fees) ari s ing from or rel ating to b eing included in the S ubmission.
Nothing herein wi ll c onstitute a ny obligatio n o n the Cospo nso rs or their a ffiliate s to make any use of the Materials.
_________________________________ ________________________
Indivi dual’s sig nature Date
(M ust be signed by hand, and not typed, st amped,
or computer g enerat ed)
_________________________________ ________________________
Parent or Legal Guar dian’s signature Date
(M ust be signed by hand, and not typed, st amped,
or computer g enerat ed)
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