Speaker Consent Form
Producer: _____________________________
Location: ______________________________
I hereby agree to your recording, videotaping and publicly exhibiting
my appearance and/or participation at your Annual Institute and Conference
Workshop and/or Session Program entitled: ________________________________________________________________________
(the Program), and in consideration of the mutual benefits flowing
from such exhibition, I agree as follows:
-
You
are the sole owner of all rights in and to the Program and its content
and recordings for all purposes and uses of any type including,
without limitation, the following rights which you may, in your
sole discretion, exercise throughout the world and forever: (a)
to publicly exhibit, distribute and/or license others to publicly
exhibit or distribute the Program, and any part(s) or edited version
of the Program, one or more times by any means of transmission now
or hereafter known (including, but not limited to broadcast by television
stations, origination or dissemination on cable TV systems, distribution
in the form of videocassettes, or direct projection before audiences),
in therefore or whether the exhibition is on a commercial and/or
non-commercial basis: (b) to publish, disseminate and edit the text
of the Program in any form, and (c) to assign all or part of any
such right to others.
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You
shall have the right to use and license others to use my name, likeness
and biographical material as I may furnish in connection with advertising
and/or publicizing the National Black Nurses Association, your agents,
your licenses, the Program ("Advertisers") and their products
or services, but not, however, as an endorsement.
-
By
signing this agreement I am releasing you, your agents, Officers
and Advertisers from and against claims of any nature arising from
reason of my appearance and/or participation in the Program, statements
made by others in, or in connection with, the Program, or your exercise
of the rights which I have granted you in this agreement.
- I agree to indemnify
and hold harmless, you, your agents, Officers and Advertisers and
you and teir officers, directors, agents and employees from and against
any and all claims, damages, liabilities, costs and expenses (including
consul fees) arising from the recording, videotaping or other publication
of any words spoken by me, my appearance, or any material furnished
by me in connection with the Program.
Your
permitting me to appear in the Program shall constitute your approval
of this agreement.
Date:
_______________________
Print
Name: _______________________________________________________________
Signature:
________________________________________________________________
Address:
_________________________________________________________________
City/State/Zip:
_____________________________________________________________
Disclosure
Statement
Disclosure of any significant financial interest or other affiliation
a presenter has with a commercial supporter of the educational presentation,
and/or the manufacturer of any commercial products discussed in the
educational presentation is requested. The existence of such relationships
does not necessarily constitute a conflict of interest, but the audience
must be informed of such affiliation of the presenter by way of acknowledgement
in the printed program. Disclosure should be provided for the relationships
or circumstances that might reasonably by expected to influence the
presenter's view on the topic.
Each
participant (including directors, chairpersons, moderators, discussants)
must return a completed disclosure statement with the submission form
or the submission will not be considered. It is the responsibility
of the submitting individual to circulate and collect disclosure statements
from all co-presenters to be included with the submission. Non-participating
co-authors Poster Submissions are not required to submit a disclosure
statement. Photocopy this form as needed.
Name
(printed/typed): _______________________________________________________________
Signature:
________________________________________________________________________
Date:
____________________________________________________________________________
Commercial
Affiliation and Relationship: ________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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