On The List - Media Release Form - BGW Elevate Magazine

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Participant Information

Participant's Name

First

Last

Participant's Date of Birth

Contact Email

Contact Phone

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Recent Head Shot:

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Upload up to three headshots for us to choose from: Plain Background, with Heads NOT cut-off, and Arms NOT cut-off...Please!

Logo Upload

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Upload a High Resolution Image of Your Logo.

Bio Upload

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Upload your Brief 1-2 minute Biography here!

Appearance Release & Consents

Consent for Photography and Videography

I hereby grant permission for my photo and video to be used by this organization.

By participating in the On The List podcast, I hereby grant permission to Broughton Media Group, Black Gay Weddings, the LGBTQBizLIst and any affiliates (Herein referred to as "BMG") to capture photographs and videos of me during the recording and related events. I understand that these images and recordings may be used for promotional purposes, including but not limited to social media, websites, and other media forms.

I agree that my name and likeness may be used in conjunction with such materials. I acknowledge that there will be no compensation for the use of my image and that "BMG" has no obligation to use the recordings or photographs. If I do not wish to be photographed or videotaped, I will withdraw from the interview session in advance.

Usage Rights

I grant "BMG" and their authorized parties the right to use, reproduce, and distribute videos and photographs of me.

The content captured during the On The List podcast, including photographs and video recordings, is the exclusive property "BMG." "BMG" reserves the right to edit, publish, and distribute these materials in any format or medium, including but not limited to online platforms, social media, promotional materials, and public presentations.

Participants acknowledge that their contributions may be included in such content and that "BMG" may use their name, likeness, voice, or statements in connection with the promotional activities. Participants grant "BMG" irrevocable rights to use, reproduce, modify, publish, and display these materials without any further approval or payment.

Participants release "BMG" from any and all claims, demands, and liabilities arising from or related to the use of such materials.

Waiver and Release

I, the undersigned, hereby acknowledge and agree to the following terms regarding my participation in the On The List podcast:

1. Voluntary Participation: I understand that my participation in the podcast, including any associated events, is entirely voluntary and that I may withdraw at any time. However, I acknowledge that any recordings created prior to my withdrawal may still be used as outlined in this agreement.

2. Assumption of Risk: I acknowledge that participating in the podcast may involve inherent risks, including but not limited to, the risk of emotional distress or discomfort due to the content discussed. I voluntarily assume all risks associated with my participation.

3. Release of Liability: In consideration for being permitted to participate in On The List podcast, I hereby waive, release, and discharge the podcast, its producers, affiliates, agents, and representatives from any and all claims, liabilities, damages, or losses arising out of or in connection with my participation, including any claims for personal injury, emotional distress, or damages to my rights of publicity or privacy.

4. Indemnification: I agree to indemnify and hold harmless "BMG" and its affiliates from any claims, damages, or costs arising from my actions, omissions, or statements during my participation.

5. Consent to Use of Likeness: I consent to the use of my name, likeness, voice, and statements as described in the Usage Clause and understand that these materials may be used without further notice or compensation to me.

6. Acknowledgment of Understanding: I represent that I have read and understood this Waiver and Release Clause, and I am executing it voluntarily. I acknowledge that this agreement is binding on myself and my heirs, assigns, and legal representatives.

Rights Name Address

Date of Interview

Please enter the date you have booked for your interview.

Participant's Signature

Clear Signature

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Andrae & Jason

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On The List – Media Release Form

Participant Information

Appearance Release & Consents

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