Photo Image Consent Form (General Use)

Authorization of Use

☑ General Use

☐ Specific Project: ________________________________

I, (type full name below) (*) hereby grant permission to the University of Kentucky and its affiliates and subsidiaries, including but not limited to the UK Alumni Association, UK Athletics Association and UK Research Foundation, to interview, photograph and/or videotape me, or my minor child, and/or to supervise any others who may do the interview, photography and/or videotaping and/or to use and/or permit others to use information from the aforementioned interview and/or the aforementioned images in educational and promotional activities for the following without compensation:

✓ University Educational Publications/Videos

✓ University Electronics Publishing (e.g. World Wide Web)

✓ Any University Social Media Initiatives

✓ University Promotion/Advertising

✓ Local/regional/national news media (w/permission of the University of Kentucky)

Signature

Date of Signature

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

If the individual to be interviewed, photographed and/or videotaped is under the age of 18, please indicate your relationship or authority to consent

Signature of Parent or Guardian

Date of Parent/Guardian Signature

Full Name

First

Last