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 Photo/Film Authorization

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Authorization for Photography, Filming, or Interviewing

Consent Form PDF

Please print
Name _____________________________________________________
Address ___________________________________________________
Home Phone __________________ Work Phone ___________________
Email Address (optional) ______________________________________

____ (initial) I hereby expressly grant the University of Minnesota the right to make, use and/or publish information, photographs, or any other reproduction of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes, audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be use for educational, marketing, and/or promotional information.

____ (initial) I hereby expressly grant consent to be photographed, filmed and/or interviewed by:

Name _______________________________________________________
Department, address, phone, email address _________________________
____________________________________________________________
Purpose ______________________________________________________

____ (initial) The University of Minnesota may use resulting media coverage in its internal or external promotional activities.
____ (initial) I understand that the University of Minnesota shall not be responsible for media’s use of any films, photographs or interviews.

Signature __________________________________________ Date _______
Parent/Guardian’s Signature (if under 18) ________________ Date _______
Witnessed (name & title): ______________________________ Date _______

The University of Minnesota is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, color, creed, religion, national origin, sex, age, marital status, disability, public assistance status, veteran status, or sexual orientation.

The University of Minnesota, founded in the belief that all people are enriched by understanding, is dedicated to the advancement of learning and the search for truth; to the sharing of this knowledge through education for a diverse community; and to the application of this knowledge to benefit the people of the state, the nation, and the world. The University’s threefold mission of research and discovery, teaching and learning, and outreach and public service is carried out on multiple campuses and throughout the state.
____________________________________________________________

Department Use Only

Photo Description ______________________________________________
It is the responsibility of the photographer and/or recorder to retain authorization forms.

University of Minnesota Duluth | 1049 University Drive | Duluth, MN 55812 | www.d.umn.edu | 218-726-8000

Consent Form PDF

 

UMD External Affairs
University of Minnesota Duluth | 1049 University Drive | 302 Darland | Duluth, MN 55812 | 218-726-6140

To send information to Currents and to submit a listing to the Experts List use umdnews@d.umn.edu.
To send major news stories for news articles, news releases and UM Twin Cities Brief use umdnews@d.umn.edu


Cheryl Reitan, Associate Director for External Affairs, 218-726-8996, creitan@d.umn.edu
Betty Greene, Associate Administrator, 218-726-6140, bgreene@d.umn.edu
Brett Groehler, Director of Photographic Services, 218-726-7115, bgroehle@d.umn.edu
Charlene Aaseng, Graphic/Multimedia Designer, 218-726-6858, caaseng@d.umn.edu
Kathleen McQuillan-Hofmann, Communication Associate, 218-726-7111, kmcquill@d.umn.edu
Lori Melton, Communication Associate, 218-726-8830, lmelton@d.umn.edu
Joel Youngblom, Web Development & Content Manager, 218-726-8798, jyoungbl@d.umn.edu
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The University of Minnesota is an equal opportunity educator and employer.
Last modified on 07/14/14 08:46 AM
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