Consent and Release Form

The Institute for the Humanities asks you to fill out the following form so that we can use images and videos for furthering our mission.  We also allow for specific requests that limit distribution.

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the UIC Institute for the Humanities to use my image and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the Internet).  This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name;

(c) Permission to use information in publications and media activities as means of furthering the Institute’s intellectual mission.  Limitations that individual presenters wish to make on specific media should be indicated below:

This consent is given in perpetuity, and does not require prior approval by me.

  • Name
  • Writing your full name here will be akin to a legal signature.
  • Email * Required
    Listing email will be akin to a signature; confirmation of signature for Photo/Video Consent and Release Form will be sent to this email.
  • (c) Permission to use information in publications and media activities as means of furthering the Institute’s intellectual mission.  Limitations that individual presenters wish to make on specific media should be indicated below:
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.