American Chemical Societ
Office of Award Programs
1155 Sixteenth Street N.W.
Washington, DC 20036
(800) 227-5558, ext. 6283
(202) 872-6283
awards@acs.org
Model Release Form
I, ____________________________________________ do hereby irrevocably
authorize, the American Chemical Society, its legal representatives, assigns, and
those acting under its permission and on its authority, to publish, and use in all
forms and media and manners for advertising, trade, promotion, exhibition, or
any other lawful purpose whatsoever, still photographic images or pictures of me
in which I may be included in whole or in part, alone or in conjunction with other
persons, or composite, or reproductions thereof, or in derivative works made
through any medium.
I do hereby waive any right that I may have to inspect or approve the finished
product or advertising or other copy that may be used in connection therewith or
the use to which they may be applied.
I hereby release and agree to hold harmless the American Chemical Society, its
legal representatives, assigns, and all persons acting under its permission or
authority, from any liability by virtue of blurring, distortion, alteration, optical
illusion, or use in composite form whether intentional or otherwise, that may
occur in any processing tending toward the completion of the finished product,
unless it can be clearly shown that the publication thereof were maliciously
caused, and produced, and published solely for the purpose of subjecting me to
conspicuous ridicule, scandal, reproach, scorn, and indignity.
I do hereby warrant that I am of full legal age and have every right to contract in
my own name in the above regard. Further, I have read the above authorization
and release, prior to its execution, and I am fully familiar with the contents
thereof.
Name ____________________________________________________________
Address ____________________________________________________________________
______________________________________________________________
Signature _________________________________________________________