Photography Release Photographer

VIDEO RELEASE–Photographer

In consideration of the video entitled ______with the appropriate credit line, I,

(name) ______hereby give The American Occupational Therapy Association, Inc., its successors and assigns, and those acting under its permission or upon its authority, the right and permission to reproduce, publish, circulate, and otherwise use the photographic image(s) described below as part of the video. I warrant that I own all legal rights and copyrights in the photograph images. I further warrant I have full authority to enter into this agreement.

The terms of this agreement shall be binding on both the photographer and The American Occupational Therapy Association, Inc. and all their respective heirs, executors, administrators, successors, and assigns.

Name of photographer (print or type) ______

Signature of photographer or authorized representative ______Note. My electronic (typed) signature on this document constitutes my legal signature in accordance with 21 CFR Part 11: Electronic Records; Electronic Signatures Act.

Address ______

______

Date ______

Description of photograph(s) ______

______

Credit line is to appear as follows:

______