SCHOOL OF OCCUPATIONAL THERAPY
COLLEGE OF HEALTH PROFESSIONS
CONSENT TO USE MEDIA
For good and valuable consideration, the receipt of which is acknowledged, I, on behalf of myself, the below-named
minors (if applicable), and any person who can claim by or through us, grant Pacific University and its School of
Occupational Therapy (“University”) permission to use my (and any minors named below) image(s), likeness(es)
and voice(s) as recorded via photographic, audio, video, digital, or other means. I/we understand that these items
may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished
product where the image(s), likeness(es), or recording(s) appears. Additionally, I/we waive any right to royalties or
other compensation arising or related to the use of my image, likeness, or recording.
Photographic, audio or video recordings may be used for student for student capstone projects, posting on the
University website (“CommonKnowledge”), publishing materials or reports related to student capstone projects,
and any other purpose the University deems proper, including, but not limited to, advertising, marketing, news
reporting, public service announcements, promotions, websites, social media, conference presentations, educational
presentations or courses, informational presentations, on-line educational courses, recruiting materials, or
educational videos.
By signing this release I/we understand this permission signifies that recordings may be electronically displayed via
the Internet or in other settings. There is no time limit on the validity of this release, nor is there any geographic
limitation on where these materials may be distributed.
By signing this form I acknowledge that I have completely read and fully understand the above release and agree to
be bound by its terms. This release is intended to be as broad as permitted under law. I/we release any and all
claims, including, but not limited to, for damage(s), libel, slander, or invasion of privacy, against the University,
including any person or entity affiliated or associated with the University, for the taking or use of these materials.
Signature of person/parent or guardian
Print name of individuals being photographed/recorded (include names and ages of minors, if applicable)
Date
Pacific University, College of Health Professions
Name of School of OT faculty/student (please print)