TEACHER MEDIA WAVIER FORM

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1PERSONAL INFORMATION & MEDIA WAVIER

2CONFIRM & SUBMIT

PERSONAL INFORMATION & MEDIA WAIVER

Items with an * are required fields.

First Name*

Last Name*

Preferred Name*

Email Address*

Media Consent and Waiver Agreement

At Global Summers Academy, a high school educational travel program operated by 2769845 Ontario Inc. (“Global Summers Academy”), we provide a rich learning environment where students learn from our teachers and from the guided collaborative work they do in location on our travel education programs. We are proud to share this environment and experience with our students, alumni, family, and friends by featuring students and their work on our websites and in other electronic media, including social media, and in print media, presentations, open houses, advertisements, and the like. To assist in publicizing our programs we request the following consents from our students and their parents or guardians.

PHOTOGRAPHS & RECORDINGS

I, the undersigned, understand that during my participation as a staff member in Global Summers Academy programs, Global Summers Academy may record my image and/or voice, both individually and as part of any group, in any physical or electronic manner including but not limited to still photographs and audio/video recordings, and that Global Summers Academy may make excerpts and compilations of these recordings (the recordings, excerpts and compilations are referred to collectively as “Recordings”) and consent to Global Summers Academy making, creating and retaining such Recordings. I authorize Global Summers Academy to make, copy, publish, display and otherwise include Recordings of me in websites and other physical or electronic media (including but not limited to social media, print, radio, television, websites or emails) published or presented by or on behalf of Global Summers Academy, which I understand will be used only in relation to Global Summers Academy programs. I further understand and agree that Global Summers Academy may decide to use or print all or part of my name in association with Recordings or may refrain from stating my name altogether.

Photographs & Recordings of Staff*

I Agree

I do not Agree

WORKS

During my participation in Global Summers Academy programs, I may create a number of works including but not limited to photographs, videos, drawings, paintings, blogs, papers, emails, texts, and surveys (referred to collectively as the “Works”). I authorize Global Summers Academy to make, copy, publish, display and otherwise include my Works or any excerpts or compilations made by or on behalf of Global Summers Academy from or including my Works, which may be combined with the Works of Global Summers Academy participants’ or members of the Global Summers Academy’s community in websites and other physical or electronic media (including but not limited to social media, print, radio, television, websites or emails) published or presented by or on behalf of Global Summers Academy, which I understand will be used only in relation to Global Summers Academy programs.

Works Agreement*

I Agree

I do not Agree

FURTHER, I AGREE AS FOLLOWS

(a) The rights I grant to Global Summers Academy herein, as applicable, are non-exclusive, meaning that I may use my Works for any other purposes, and Global Summers Academy is entitled to carry out any of its permitted activities regarding Recordings or Works without payment to me, unless otherwise disclosed.

(b) Title to all Recordings, photographs, videos or other publications or reproductions made by Global Summers Academy (including Global Summers Academy photographs or recordings of me or my Works) belongs to and remains with Global Summers Academy. I understand that I am not permitted to copy or publish anything described in the preceding sentence in any manner, including without limitation copying or uploading pictures of me or my Works taken by Global Summers Academy from any Global Summers Academy website onto any hard drive or other website.

(c) Under no circumstances does Global Summers Academy incur any liability to me or other parties in respect of any use by me or other parties of any material described herein, or any Recordings or copies of me or my Works made by parties other than Global Summers Academy, that is carried out without the prior written consent of Global Summers Academy, and I release Global Summers Academy in respect of all such liability on behalf of myself and anyone who may claim through me.

(d) Any rights or release granted to or retained by Global Summers Academy may be used by and accrues to the benefit of Global Summers Academy and its parent, related, subsidiary or affiliated entities and any and all of their respective officers, directors, agents and employees and all of the heirs, executors, personal representatives, administrators, successors and assigns of all of the foregoing parties.

ACKNOWLEDGMENT AND SIGNATURE

I have carefully read and understand this Media Consent and Waiver Agreement, including the implications and consequences of executing same. By signing this agreement, I voluntarily accept and agree to be bound by the terms contained herein.

Acknowledgment & Signature*

I Agree

I do not Agree