Home Phone __________________ Work Phone ___________________
Email Address (optional) ______________________________________
____ (initial) I hereby expressly grant the University of Minnesota the right to make, use and/or publish information, photographs, or any other reproduction of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes, audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be use for educational, marketing, and/or promotional information.
____ (initial) I hereby expressly grant consent to be photographed, filmed and/or interviewed by:
Department, address, phone, email address _________________________
____ (initial) The University of Minnesota may use resulting media coverage in its internal or external promotional activities.
____ (initial) I understand that the University of Minnesota shall not be responsible for media’s use of any films, photographs or interviews.
Signature __________________________________________ Date
Parent/Guardian’s Signature (if under 18) ________________ Date _______
Witnessed (name & title): ______________________________ Date _______
The University of Minnesota is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, color, creed, religion, national origin, sex, age, marital status, disability, public assistance status, veteran status, or sexual orientation.
The University of Minnesota, founded in the belief that all people are enriched by understanding, is dedicated to the advancement of learning and the search for truth; to the sharing of this knowledge through education for a diverse community; and to the application of this knowledge to benefit the people of the state, the nation, and the world. The University’s threefold mission of research and discovery, teaching and learning, and outreach and public service is carried out on multiple campuses and throughout the state.
Department Use Only
Photo Description ______________________________________________
It is the responsibility of the photographer and/or recorder to retain authorization forms.
University of Minnesota Duluth | 1049 University Drive | Duluth, MN 55812 | www.d.umn.edu | 218-726-8000
University of Minnesota Duluth
1049 University Drive
Duluth, MN 55812
Director of External Affairs
Associate Director for External Affairs
Director of Photographic Services
Web Development & Content Manager
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