Attachment_A_NPSIndividualReleaseForm.doc

Attachment A

I hereby grant the National Park Service, or its authorized representatives and contractors, the right to make visual recordings, audio recordings, still images, and/or to otherwise capture material of me and any minor child under my control at the time the material is collected.

I hereby agree that the material will become the property of the National Park Service and will not be returned. As such, I agree that the National Park Service and its assigns have the right to reproduce, prepare derivative works of, distribute or display and use these materials in whole or in part, for government and non-government purposes, in any manner or media (whether now existing or created in the future), in perpetuity, and in all languages throughout the world. Use of this material shall include, but not be limited to, audiovisual programs; museum exhibits; websites; publications; product artwork; and project publicity. Additionally, I waive the right to inspect or approve any use of the material and any right to royalties or other compensation arising or related to the use of the material.

I hereby hold harmless and release and forever discharge the National Park Service from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am 18 years of age or older and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning and impact of this release. I agree to indemnify and hold the Government harmless for any and all losses, claims, expenses, suits, costs, demands and damages or liabilities on account of personal injury, death, or property damages of any nature whatsoever and by whomsoever made, arising out of the activities associated with the project in which I am taking part.

Description of Material: ______________________________________________________________

Signature/Date: ____________________________________________________________________

Printed Name______________________________________________________________________

Address: __________________________________________________________________________

City: __________________________________________State: _______Zip Code: _______________

Phone (please include area code):______________________________________________________

Organization/Group Name (if applicable):_________________________________________________

If the person signing is under age 18, there must be consent by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of _______________________________, named above, and do hereby give consent without reservation to the foregoing on behalf of this person.

Parent or Guardian’s Signature/Date______________________________________________________

Parent or Guardian’s Printed Signature____________________________________________________

For NPS/Contractor Administrative Use Only:

Park� Project� Location � Date � Contractor�

NPS COR�

Privacy Act Statement: This information is provided to comply with the Privacy Act (PL 93-579). 5 U.S.C. 301 and 7 CFR 260 authorizing acceptance of the information requested on this form. The data you furnish will be used only to provide the National Park Service with contact information pertaining to this release form.

Print Name and Title: __________________________________________

Your Signature: ______________________________________________

Date: ___________________

Address: _____________________________________________________________________________

City: ________________________________________ State: __________ Zip Code: __________

Telephone (please include Area Code): _____________________________________________________

Organization/Group Name (if applicable): __________________________________________________

Privacy Act Statement

This information is provided to comply with the Privacy Act (PL 93-579). 5 U.S.C. 301 and 7 CFR 260 authorize acceptance of the information requested on this form. The data you furnish will be used only to provide Harpers Ferry Center with contact information pertaining to this release form.

FOR OFFICE USE ONLY:

SEMO NLSoF 2004 Amber Perkins

Park Program # Location Date AV Rep

Attachment C – Page 1 Revised 02/20/2004

NPS Individual Release Form

National Park Service

U.S. Department of the Interior