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.
- 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 their 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
Your
permitting me to appear in the Program shall constitute your approval
of this agreement.
Date:
_______________________
Print
Name: _______________________________________________________________
Signature:
________________________________________________________________
Address:
_________________________________________________________________
City/State/Zip:
_____________________________________________________________
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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: ________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PLEASE SUBMIT MATERIALS TO:
Dianne Mance, Conference Services Coordinator
National Black Nurses Association
8630 Fenton Street, Suite 330, Silver Spring, MD 20910
Fax: (301) 589-3223
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