Attachment_B_NPS_MaterialsReleaseForm.doc

Harpers Ferry Center Release Form

National Park Service

U.S. Department of the Interior

I agree to participate in a National Park Service project and grant the National Park Service the absolute and irrevocable rights and permission to use the collected material of me, and any minor child under my control at the time the material is collected, and/or material created or supplied by me (check all that apply):

O Motion Picture, Video and/or Still Photography O Narration/Voice Over

O Audio Recordings O Oral History Interview

O Music Recordings O Other: Specify_______________

I agree that the above referenced material can be used for the life of the project in (check all that apply):

O The below-referenced National Park Service project

O Future National Park Service projects

O Projects outside of the National Park Service

I agree that the above-referenced material can be used in the following manner (check all that apply):

O Unlimited Rights or:

O Non-commercial, Educational, and Archival Use O Distribution

O Public Broadcast/Community Access TV O Internet

O Commercial Educational Use – sold for private home use (non-profit sales only)

Indemnification

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 production in which I am taking part.

I agree, that as the signee of this release form, I must consent, in writing, to any additional use of the above-referenced material not agreed to in this form.

Print Name: __________________________________________________________________________

Your Signature: ______________________________________________ Date: ____________________

Address: _____________________________________________________________________________

City: ___________________________________________State: ________ Zip Code:_______________

Telephone (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.

Release Form Definitions

A. Non-commercial, Educational and Archival Use:

Non-commercial: The material used, whether, for example, in a publication, video, audio or interactive program, will not be sold.

Educational: The material will be used to educate viewers in a particular subject matter. For example, the material may be used in an interactive computer program in a National Park Service Visitor Center, a publication made available in a National Park Service Visitor Center, a video shown at the National Park Service Visitor Center, or an audio station used in an exhibit at a National Park Service Visitor Center.

Archival: The material can be accessed by anyone for research purposes.

B. Distribution: The material may be distributed. For example, a video production in which the material is used may be distributed to schools, state parks, other public land use sites, or to other individuals or organizations who may use it as a part of their programming.

C. Public Broadcast and Community Access Television: The material may be used in a production that is broadcast on a non-commercial television station, such as a local PBS affiliate or local community cable access station.

D. Internet: The material can be published on the internet.

E. Commercial Educational Use—Sold for Private Home Use (non-profit sales only): The material may be used in a project that is sold. However, sale is non-profit. For example, a friends group of a National Park Service site may wish to sell the video shown at their National Park Service site’s Visitor Center. The proceeds of this video will in turn go towards the duplication of additional videos and DVD’s and to the National Park Service in general for other educational and support-related efforts.

F. Unlimited Rights: The right of the Government to use, disclose, reproduce, prepare derivative works, distribute copies to the public, and perform publicly, in any manner and for any purpose whatsoever, and to have or permit others to do so in perpetuity.

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