I hereby grant full permission to Western Carolina University to prepare, use, reproduce, publish, distribute and exhibit my name, picture, portrait, likeness or voice, or any or all of them in or in connection with the production of a motion picture film, television tap or film recording, sound track recording, computer or network distributed computer file, or still photography in any manner for educational, treatment, scientific, publication, informational and any other professional purpose deemed necessary, and

I hereby waive all right of privacy or compensation which I may have in connection with the use of my name, picture, portrait, likeness or voice, or any or all of them, in or in connection with said motion picture film, television tape or film recording, sound track recording, computer or network distributed computer file, or still photography and any use to which the same or any material therein may be put, applied or adapted by Western Carolina University, and any of its agencies, i.e. schools, departments, or divisions.

This consent and waiver will not be made the basis of a future claim of any kind against Western Carolina University and any of its agencies.

IN WITNESS WHEREOF I have hereunto set my hand and seal this______________ day of ___________________ , 19 _____ .

NAME: ____________________________________
(signature)

ADDRESS: ________________________________


_______________________________

SIGNATURE OF PARENT OR GUARDIAN:* _________________________
*When minor is recorded or when otherwise justfiable.