Fillable Printable Video Informed Consent Form

Video Informed Consent Form

VIDEO CONSENT FO RM (the “For m”)

SBA Visa Export Video Contest (the “Contest”)

Instructions for Video Submitter:

Anyone that appears in the Video must complete and sign this Form. If a minor appears in the Video, the minor’s parent/legal

guardian must also sign this Form. Print this form and ensure it is completed by hand. Scan the form and combine all scanned forms

into one single file (ZIP, PDF, or doc).

A Submission (as d e fined in the Contest’s Officia l R ules) wi ll no t be final until the U.S. Small Business Administration (SBA) and Visa

U.S.A, Inc. (Visa), collectively the “Cosponsors”, receive a completed form(s) for each individual that appears in the Video. The

completed Form must be uploaded as part of a Submission.

Information of Individual appearing in the Vid eo

(required):

Name: _______________________________

Phone Number:_________________________

Parent or Legal Guardian’s Information (required if

the individual is a minor ) :

Name: _______________________________

Address: _______________________________

Phone Number:__________________________

Relation sh ip to Minor :_____________________

I represent and warrant that:

1. I have read, understood and agree to the Contest’s Official Rules located at [INSERT URL] (the “Rules”);

2. I under s tand that I am provi ding ce rta in rig hts t o the C osp onsors in connection with the Vi deo, including, but not

limited to

a. gra nting to the C osponsors and other acting on their behalf, a perpetual, irrevocable, royalty-free none xcl usive

worldwide license to copy, distribute, modify, display and perform publicly and otherwise use, and authorize

ot hers t o use , the Submission for any educational purpose throughout the world and in any media, and license

others to do the same, the Submission, for the purpose of the Contest, includin g po sti ng or linking t o the

Submission on the Cosponsors’ websites and social media pages and ma kin g it available to the general public

fro m its resp e c tive web sites and soc ia l media pages and to distr ibute it to groups and an y o ther organizations

interested in showing it for educational purpo se s, including, but not li mited to, Inter net site s, c onferences and

events, o n televisio n, and other media o utlets; and

b. the right and permission to record, copy, reproduce, adapt, edit, summarize, publish, exhibit, distribute and

otherwise exploit by any and all uses and media, now k nown or hereafter devised, throu gho ut the univer s e until

one year after the announcement of winners (collectively, “Use”), my or my minor individual’s appearance,

name, like ness, and voice in any ma nner, format or context whatsoe ver (collectively, the “Materials”). Said

grant shall include, without limit ation, the right for t he Cosponso rs and those a cting on b ehalf o f t he Cosponsors

to use the Materials i n and in connection with the Contest, in any other video , film or te levision program, in

print, ele c tr onic and or photo/essay material s and publication, and in all types of advertisi ng a nd promotion

relatin g to the Contest.

3. I hereby waive any right to inspect or approve Materials or the Use to which such Materials may be applied.

I release, discharge, and hold harmless the Cosponsors from and against any and all claims that I (and the minor)

ma y have arising from or i n connection with my partic i pation in the Submi s s i on and its related events. I further

agree to indemnify, defend, and hold the Cosponsors harmless against any and all los ses, claims, and expenses

(includ ing reasonable attorneys’ fe es) ari s ing from or re lati ng to being includ ed i n the Submission.

Nothing her e in will const itute any obligation on the Co sp ons ors or their a ffiliate s to make a ny use of the Materials.

_________________________________ ________________________

Individual’s s ignature Date

(Must be signed by hand, and not typed, st amped,

or computer generated)

_________________________________ ________________________

Parent or Legal Guardian’s signature Date

(Must be signed by hand, and not typed, st amped,

or computer generated)