R 4/15
I hereby grant Johnson County Community College (“JCCC”) a limited, non-exclusive, perpetual license
to copy, publish, perform, create derivative works, incorporate into compilations or collective works, and
distribute the works of authorship I created during the below identified JCCC credit class (collectively,
the “Works”) for educational purposes; and for promoting, marketing and advertising JCCC and its
educational services worldwide. Works of authorship to which I have granted JCCC the foregoing rights
include, but are not limited to, literary works, musical works, dramatic works, pantomimes and
choreographic works, pictorial, graphic and sculptural works, motion pictures and other audiovisual
works (such as video games and animation), and sound recordings.
Course Name ____________________________________________
Course Section ___________________________________________
Term Enrolled ____________________________________________
I certify that no other individual or parties hold copyright interest in the work(s) described above, that I
hold all rights to the works listed, and that the license granted herein does not violate any third-party
rights or applicable laws. I hereby certify and covenant that I am of legal age (a parent or legal guardian
must sign for a minor), or if applicable, that I am authorized to sign on behalf of the entity listed below.
Printed Name ____________________________________
Signature ________________________________________
Date ____________________________________________
Street Address ____________________________________
City, State _______________________________________
ZIP Code ________________________________________
Phone Number ____________________________________
Email Address ____________________________________