VIVA! Peer Tutors 2012 Health Literacy Video Contest COPYRIGHT FORM

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1 COPYRIGHT FORM Every entrant must complete and submit this form together with ALL OTHER FORMS. Please do not send separately. All forms must be received by March 19, Please complete this form and to No video will be judged without this information. No faxed forms will be accepted. Type or print clearly. SECTION A Video title Entrant s full name Entrant s address If you are submitting a video as a team complete section B SECTION B Team member #1 name Team member #2 name SECTION C Entrant s school name School address School phone number Entrant s grade Did this video include the use of any copyright-protected music, logos, images, characters or symbols? YES NO If YES, please explain and attach permission forms, copy of royalty-free music source, synchronization license, etc. I verify I am a legal resident of the United States. Signature of Entrant and Date Signature of Parent/Guardian Contract No. HHSN C with the Houston Academy of Medicine-Texas Medical Center Library.

2 MEDIA RELEASE All individuals featured in the video must complete and submit this form. Entrant s/actor s Full Name print clearly I hereby grant the VIVA! Peer Tutor Project, a subcontractor of the South Texas Independent School District, permission to use my child s name, photo and comments for any or all promotional materials (advertisements, literature, news articles, etc.) in any or all media formats (video, audio, print, electronic, etc.). I hereby grant entities related to the VIVA! Peer Tutor Project, a subcontractor of the South Texas Independent School District, permission to use my child s name, photo and comments for any or all promotional materials (advertisements, literature, news articles, etc.) in any or all media formats (video, audio, print, electronic, etc.). Parent/Guardian Name Parent/Guardian Signature Date

3 RELEASE OF CLAIMS Every entrant must complete and submit this form. NOTICE: THIS DOCUMENT HAS IMPORTANT LEGAL CONSEQUENCES, INCLUDING A RELEASE OF LIABILITY FOR INJURIES SUFFERED DURING THE ACTIVITY, AND AN AGREEMENT TO INDEMNIFY SOUTH TEXAS INDEPENDENT SCHOOL DISTRICT FOR CLAIMS ASSERTED AS A RESULT OF SUCH INJURIES. IF YOU HAVE ANY QUESTIONS REGARDING THE EFFECT OF THIS RELEASE, YOU ARE ENCOURAGED TO CONSULT LEGAL COUNSEL. For and in consideration of participating in the VIVA! Peer Tutors 2012 Health Literacy Video Contest, and on behalf of my minor child, I hereby release and discharge the South Texas Independent School District (South Texas ISD), its trustees, administrators, teachers, employees, officers, agents, volunteers and assigns, all both in their official and in their individual capacities, from any and all claims or causes of action for personal injury or property damage caused by, arising out of or in any way related to the above-described Health Literacy Video Contest. I specifically understand that the contest is not being conducted or controlled by South Texas ISD, but by the National Library of Medicine and the VIVA! Peer Tutors as a subcontractor of South Texas ISD. THIS RELEASE EXPRESSLY EXTENDS TO ALL CLAIMS OR CAUSES OF ACTION OF ANY ORIGIN, INCLUDING THOSE ARISING AS A RESULT OF THE NEGLIGENCE OF THE SOUTH TEXAS INDEPENDENT SCHOOL DISTRICT, ITS TRUSTEES, ADMINISTRATORS, TEACHERS, EMPLOYEES, OFFICERS, AGENTS, VOLUNTEERS AND ASSIGNS, ALL BOTH IN THEIR OFFICIAL AND IN THEIR INDIVIDUAL CAPACITIES, OR ANY OTHER PERSON OR ENTITY, WHETHER BY ACT OR OMISSION. I FURTHER AGREE AND COVENANT TO NOT SUE THE SOUTH TEXAS INDEPENDENT SCHOOL DISTRICT, ITS TRUSTEES, ADMINISTRATORS, TEACHERS, EMPLOYEES, OFFICERS, AGENTS, VOLUNTEERS AND ASSIGNS FOR SUCH CLAIMS OR CAUSES OF ACTION. I further agree to indemnify and hold harmless the South Texas Independent School District, its trustees, administrators, teachers, Release of Claims-Page 1 of 2

4 employees, officers, agents, volunteers and assigns, all in both their individual and their official capacities, from any damages or loss arising from any claim or cause of action for personal injury or property damage asserted by myself or anyone acting by, for, through, under or on account of myself. THIS INDEMNIFICATION AGREEMENT EXPRESSLY EXTENDS TO ALL CLAIMS OR CAUSES OF ACTION OF ANY ORIGIN, INCLUDING THOSE ARISING AS A RESULT OF THE NEGLIGENCE OF THE SOUTH TEXAS INDEPENDENT SCHOOL DISTRICT OR ANY OTHER PERSON OR ENTITY, WHETHER BY ACT OR OMISSION. I UNDERSTAND THAT THIS RELEASE AND INDEMNIFICATION WILL BIND ME, MY ASSIGNS, MY PERSONAL REPRESENTATIVES AND MY HEIRS. I further acknowledge that I will abide by all rules and regulations concerning the contest and that I will not violate the Federal Family Education Rights to Privacy Act by disclosing any confidential information pertaining to students at this district. I expressly declare that I have read this Release of Claims and understand all of its terms and conditions. I execute this Release of Claims voluntarily and with full knowledge of its significance. DATE:, (Signature of Student/Participant) (Printed Name of Student/Participant) (Signature of Parent/Guardian) (Printed Name of Parent/Guardian) (Address of Student and Parent/Guardian) (City/Town, State, Zip Code) Release of Claims-Page 2 of 2

5 VALIDATION FORM Only one validation form is required for each video submission. Please complete this form and it to No video will be judged without this information. No faxed forms will be accepted. Type or print clearly. SECTION A Video title Entrant s full name If you are submitting a video as a team complete section B SECTION B Team member #1 name Team member #2 name How many members of your team used MedlinePlus PRIOR to creating your video? SECTION C Entrant s school name School address School phone number Entrant s grade SECTION D School sponsor s full name Sponsor s position: Teacher Librarian Counselor Principal Sponsor s phone number I verify that only the entrant and his/her team members worked on the production of this video. I understand and have explained to the entrant and his/her team members that this provision has been included to prevent any type of professional assistance in completing the video. I believe that all work in this video is the original work of the entrant and his/her team members, and that the entrant/team has fulfilled all the requirements for this contest, which includes compliance with applicable copyright laws and adherence to the contest guidelines. Sponsor s Signature Date Contract No. HHSN C with the Houston Academy of Medicine-Texas Medical Center Library.

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