AMERICAN CHEMICAL SOCIETY

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AMERICAN CHEMICAL SOCIETY STUDENT VIDEO RELEASE FORM For consideration which I acknowledge, I hereby grant to the American Chemical Society, its affiliates and licensees (collectively referred to as “the ACS”), royalty-free permission, including the exclusive worldwide, irrevocable rights in all languages, to reproduce in all formats, including, but not limited to print, microfilm, electronic, video, and/or CD-ROM, my likeness as shown in the video(s) taken of me for the 2018 Chemists Celebrate Earth Week Contest. ____________________________________________________________________________ Further, I hereby waive my right to inspect or approve any copy that is used in connection with the video/photograph(s) and release and discharge the ACS from any and all claims arising out of use by the ACS of the video/photographs, including any claims for libel and invasion of privacy. The ACS is permitted, although not obligated, to include my name as a credit in connection with the image. The ACS is not obligated to utilize any of the rights granted in this Agreement. I have read and understood this agreement and I am over the age of 18. This Agreement expresses the complete understanding of the parties.

_______________________________________________ Signature Printed Name: ___________________________________ Date: __________________ Complete Address: _______________________________________________________________________ If under age 18, a parent or guardian must complete the following: Approval: _______________________________________________ Signature Printed Name: ___________________________________ Date: __________________ Complete Address: ________________________________________________________________________ Parental authority (e.g. Mother, Father, etc.): _______________________________________________