Student Release for Video Taping and/or Photography Form

If requested below, as far as is possible, my anonymity will be maintained. I also
understand that, upon written request, I will be shown any videos or photographs and have the
opportunity to refuse their distribution unless my image is blurred, pixelated or otherwise
obscured.

All fields marked with asterisk (*) are required.

required text field

Your Name:*

required checkbox field

I consent to allow Emory & Henry College faculty, staff and/or identified individuals to videotape or photograph me during School and Program related activities.*

Yes

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I consent to future use of the resulting video and/or photographs in College, School and Program advertisement, articles, books, classroom case studies, or presentations at professional conferences.*

Yes

required checkbox field

You may reveal my name or use it in presentations/publications.*

If you do not want your name used then select "No"

Yes

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You do not need to cover my face in images to maintain anonymity.*

If you want your face to be covered to maintain anonymity then select "No"

Yes

required date field

Date Submitted:*

Link (required)