Affidavit of Eligibility & Liability & Publicity Release
I represent that I am eligible to participate in the City of Clermont’s Photo Challenge.
I represent that I satisfy all eligibility requirements set forth in the official rules, which I acknowledge having read and
understood, and any other requirements by law.
I release the City of Clermont from all liability, injuries, loss and/or damage of any kind arising from my participation in
the Photo Challenge.
I have not perpetuated and will not perpetrate any fraud or deception in connection with the Photo Challenge.
I consent to give the City of Clermont a royalty-free, irrevocable, perpetual, non-exclusive license to use, reproduce,
modify, publish, create derivative works from, and display any phot submission, in whole or in part, on a worldwide
basis, and to incorporate it into other works, in any form, media or technology now known or later developed, including
for promotion and marketing purposes.
I certify that this submission does not infringe on the intellectual property (copyright, trademark, patent) rights of any
third party rights holder, or feature artwork created by another person, that any copyright holder of the submission has
granted permission to participate in this Photo Challenge, and had granted o will grant, to the City of Clermont the right
to publish a winning submission, and that any person featured in the photo who is a minor is my child or that the parent
or legal guardian has consented to permit their likeness to be used in the photo.
I certify that I fully understand the contents of this Affidavit signed by me and that the statements are true and correct.
Print Name: _________________________________________________________
Signature: _________________________________________________________
Date: _________________________________________________________
If Under 18 years of age, this form must be signed by a parent/guardian
Print Name: ________________________________________________________
Signature: ________________________________________________________
Date: ________________________________________________________
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