Video Release form
I grant my permission for the contents of the video I submit to be used to promote participation in the 2020 census.  


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Email *
I am over 18 years of age *
Names of my minor children who appear in the video I am submitting
By typing my name I am electronically signing the individual release below to grant the CT Association for Human Services, CT Early Childhood Alliance and Count All Kids CT permission to use my video to promote the census. *

I, the undersigned, hereby grant permission to , CTECA/CAHS/COUNT ALL KIDS CT, the Producer of this video “kids count” the right to use my full name, biography, video image, likeness, and audio collected during this production.
I also grant permission to record my image, voice, and performance, and transfer to the filmmaker/photographer all rights, title, and interest in the interview and video documentary. This includes, without limitation, the literary rights and the copyright of my picture, photograph, silhouette, other reproductions of my physical likeness and my voice collected in connection with the unlimited distribution, advertising, promotion, exhibition, and use throughout the world and in perpetuity and on whatever media is known or hereafter devised.
I agree that I will not assert, maintain or consent to others bringing any claim, action, suit or demand of any kind or nature whatsoever against the Producer including but not limited to, those grounded upon invasion of privacy, rights or publicity or other civil rights, or for any other reason in connection with the authorized use of my physical likeness and sound in Artists as herein provided.  I hereby release the Producer, its directors, officers, successors and assigns from and against any and all claims, liability, demands, actions, causes of action(s), costs, expenses and damages whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of the rights granted to the Producer herein.
The Producer, in return, agrees to retain the integrity of the interviewee's image and voice, neither misrepresenting the interviewee's words nor taking them out of context. I attest that I have voluntarily agreed to be interviewed and that this document contains the entire and complete agreement concerning the use and preservation of my interview.
I, the undersigned, shall not be given any fees for the services provided for this production.
A copy of your responses will be emailed to the address you provided.
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