Consent and Release Form

The Department of Art History 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.

With our thanks, please attest to the following:

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the UIC Department of Art History 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 Department'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.

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Please type your full name here in lieu of an ink signature.
Email * Required
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Confirmation of signature for Photo/Video Consent and Release Form will be sent to this email.
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Limitations on permissions
(c) Permission to use information in publications and media activities as means of furthering the Department’s intellectual mission. Limitations that individual presenters wish to make on specific media should be indicated above.
Consent * Required
I agree to the privacy policy.
The Department of Art History 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 Department of Art History at UIC 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 department’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.
Date * Required
MM slash DD slash YYYY

Consent and Release Form

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