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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
FILMING ON CAMPUS
For information on Filming on Campus see Publicizing Events at UMD
University of Minnesota Duluth
1049 University Drive
302 DAdB
Duluth, MN 55812
218-726-6140
umdnews@d.umn.edu
Lynne Williams
Director, University Marketing and Public Relations
218-726-6141
lwilliam@d.umn.edu
Cheryl Reitan
Associate Director, University Marketing and Public Relations
218-726-8996
creitan@d.umn.edu
Betty Greene
Administrative Associate
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
Dave Cowardin
Videographer
218-726-8798
cowardin@d.umn.edu
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