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CA Joint Special Populations Advisory Committee Media/Photo Release Form
The CA Joint Special Populations Advisory Committee (JSPAC) virtual sessions will be recorded. When an individual enter these events, they will be entering an area where video, audio recording and photography may occur. Your entrance into the virtual session will serve as your voluntary agreement to permit JSPAC and its affiliates, representatives and licensees to use your image, likeness, voice, and comments made by you and/or information obtained about you (including your name) for editorial, promotional, marketing or other purposes in any media now known or hereafter devised.

You release the JSPAC and its members, staff, representatives and affiliates from any liability connected with such filming, photography or recording. You waive any claims you may have against the JSPAC and its members, staff, representatives and affiliates from the use of your image, likeness, voice, comments made by you or information obtained about you. You have been fully informed about your consent, release and waiver before registering for and/or entering the event.

I understand and agree that these materials will become the property of JSPAC and will not be returned. I hereby irrevocably authorize the JSPAC to edit, alter, copy, exhibit, publish or distribute this media/photos for purposes of publicizing its programs or for any other lawful purpose.

Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge JSPAC 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 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.
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Print or type First/Last Name *
Signature or type First/Last Name *
I am over 18 years of age. (NOTE) If no, a parent/guardian must give consent. *
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
Parent/Guardian Print or Type First/Last Name
Parent/Guardian Signature or Type First/Last Name
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