Hearts & Minds - Information for ChangeSM Our World - Our Future: Youth for ChangeSM Consent Form for Parents/Guardians

Dear Parent or Guardian,

Hearts & Minds welcomes the participation of your child in the program, Our World - Our Future: Youth for Change^SM. Children and youth of all ages are creating thought-provoking, inspiring posters, essays, poetry and other works of art to be seen locally and internationally through our website and other media. This program is in New York City and eventually will expand all over the world.

We plan to film and/or photograph the participants and their artwork to raise awareness of poverty, the environment or other important issues in NYC and around the world, and also to support and promote Hearts & Minds' public service.

Hearts & Minds Network, Inc. is an all-volunteer, nonprofit 501(c)(3) tax exempt organization that uses mass communication to promote self-help, volunteering and community service. Our work empowers people all over the world to work on poverty, the environment, human rights, democracy, addictions and other important issues.

Founded in 1996, we are uniquely dedicated to using mass communications to inspire, motivate, inform and empower as many people as possible - in New York City, nationwide and beyond.

Our website - www.change.net - provides resources, links and practical advice that enable millions of people worldwide to help themselves and others in need. We bring together young volunteers and experienced professionals to help solve persistent social problems.

Our Global Survival Campaign - www.globalsurvival.info - directly addresses terrorism, poverty and environmental issues that threaten people everywhere.

We appreciate your interest in helping us help others.

Please carefully review the permission form below. If you have any questions, feel free to ask. If agreeable, please fill out and sign. Thanks.

Sincerely,

William Blackman
Founder/President

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Hearts & Minds - Information for ChangeSM Our World - Our Future: Youth for ChangeSM Release Authorization and Agreement to Hold Harmless

This is an Agreement between Hearts and Minds Network, Inc. and all individual(s) specified below.

I, ______________________________, am at least 18 years old. I am also the parent/legal guardian of any other individuals listed below.

I hereby give full permission for myself and my child(ren)/ward(s) (referred to here as "we" and "us") to participate in programs run by Hearts and Minds Network, Inc., its partner organizations, its licensees and assignees (collectively referred to as "Hearts & Minds" and "them").

We also give Hearts & Minds the irrevocable, exclusive and unrestricted rights and permission to create, copy, edit, alter, use, re-use, publish, re-publish, license, assign and distribute all the artwork, text, photos, motion pictures, photographic portraits and/or interviews in which we or our artwork may be included in whole or in part as a result of our participation in Hearts & Minds' programs, whether accurate or distorted in character or form, without restriction as to changes or transformations (collectively, the "Released Words and Images") in conjunction with our own names, fictitious names or no names at all.

We understand that Hearts & Minds may provide appropriate credit to us for the work. However, Hearts & Minds reserves the right to decide the manner in which credit is provided.

We grant to Hearts & Minds the foregoing exclusive rights regarding the Released Words and Images in any and all media now or hereafter known, including but not limited to any print publication, video, film, telecast, exhibition, website and digital reproduction.

The Released Words and Images can be used for illustration, art, promotion, public relations, fundraising, advertising, trade, stock photography, promotion of any goods or services, or any other purpose whatsoever.

We acknowledge that Hearts & Minds is and shall be considered the author of all Released Words and Images under all applicable copyright laws whether foreign or domestic and owns and shall own all Released Words and Images in all forms. If there is a conflict between any applicable laws or an absence of comparable laws, those of the United States of America will apply.

We hereby relinquish any right that we may have to examine or approve: (1) the completed product or products or any associated advertising copy, printed matter or images incorporating or associated with the Released Words and Images, (2) any other materials or media that may be used in conjunction with the Released Words and Images, or (3) the use to which the Released Words and Images may be applied. Also, Hearts & Minds does not guarantee that any of the Released Words and Images will be used or published.

We hereby release, discharge and agree to hold Hearts & Minds harmless from any liability to us or others associated with us by virtue of any blurring, distortion or alteration of the Released Words and Images, or use of the Released Words and Images in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said Released Words and Images or in any subsequent processing, publication or usage thereof. We also agree that this entire Release Authorization and Agreement to Hold Harmless shall continue permanently, regardless of whether any Released Words and Images used within the scope of this Agreement cause us to ever feel embarrassed, ashamed, degraded or otherwise injured in any manner.

If anyone makes use of our words or images in a way that is not authorized by Hearts & Minds and that we find deeply objectionable, we can take appropriate legal action against only those unauthorized parties. We will continue to hold Hearts & Minds completely harmless and free of liability, and will take no actions against Hearts & Minds, nor require its participation in our independent legal actions.

We hereby release, discharge and agree to hold Hearts & Minds harmless from any liability resulting from any injury or accident, regardless of cause, in which we are involved before, during or after any events, photo shootings, interviews or other meetings with Hearts & Minds.

Regarding our statements for possible artistic or commercial use by Hearts & Minds, we may be asked many questions before, during or after the event(s), but we do not have to answer any of them. We are not obligated to explain why we do not want to answer a question. We agree to allow our statements to be quoted in whole or in part or presented in an edited form, in any order, with or without attribution, in any media, as long as they do not grossly distort the meaning and intention of what we said when clearly and specifically connected with our names. Our statements and ideas may be used and combined with others’ with complete freedom when not clearly and specifically connected with our names.

If any disputes arise regarding this Agreement, both parties will make every reasonable effort to resolve them by mutually acceptable, impartial conflict resolution. If they cannot agree on an arbitrator, all conflicts shall be resolved according to the laws of New York State and shall be brought before the courts of that state.

This Agreement constitutes the entire Agreement between the parties with respect to the subject matter hereof and shall supersede all previous communications, representations, understandings and agreements, either oral or written, between the parties or an official or representative thereof. This Agreement can only be modified in writing and only when signed by both parties.

This entire Agreement shall inure to the benefit of Hearts & Minds, its agents, licensees, representatives and assigns and shall be binding upon us and our heirs, legal representatives and assigns. If any part of this Agreement is found to be unenforceable, all remaining provisions shall remain in force.

I HEREBY AFFIRM that I have read carefully this Release Authorization and Agreement to Hold Harmless prior to its execution. I had an opportunity to have all of my questions answered completely and to fully consider this Agreement. I completely understand and fully agree to the contents thereof.

I am at least 18 years of age and have the legal right and authority to contract for this Agreement for myself and any minors named herein. I hereby release Hearts and Minds Network, Inc. from any claim or liability whatsoever in connection with our participation in any activities with Hearts & Minds, the use of artwork, film, other intellectual property and accompanying disclosures.

Please print:

My full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Apt. #: |__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__| State: |__|__| Zip Code: |__|__|__|__|__|

E-Mail (optional): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|__|

Phone number(s): |__|__|__| - |__|__|__| - |__|__|__|__| and |__|__|__| - |__|__|__| - |__|__|__|__|

Signature: _______________________________________________

My age (not required if I am 18 or older): |__|__|   Date: ____/____/0__

If you do not want you or your participants to be identified by last name, place your initials here: |____|

Participant(s) under age 18 (please print):

1. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

2. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age:|__|__|   Signature: _______________________________________________

3. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

Feel free to Contact Us if you have any additional questions or concerns:


Hearts & Minds
3074 Broadway
New York, New York  10027 (USA)
1-212-280-0333
E-mail: mail@change.net
 

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This web page and entire website © Copyright: 1997 - 2007 by Hearts and Minds Network, Inc.
http://www.heartsandminds.org/youth/release.htm - online August 20, 2003, latest changes October 25, 2007