Microsoft Word - Standard Release Form.doc



STANDARD RELEASE FORMFor use of photographs, audio files, video clips, biographical information, and quotations from interviews For patient consent use dedicated form I, Click here to enter text.(the “Licensor”), give my permission to include any images, video clips, audio files, biographical information, and interview quotations from which I Click here to enter text.may be identified (the “Material”).in Click here to enter text.(the “Work”) to be published by John Wiley & Sons, Inc. or one of its affiliated companies (“Wiley”).I grant Wiley the right to use this Materialin the Work and in any related derivative and ancillary Works published by Wiley or its licenseesfor worldwide distributionin all formats and platforms in any and all media now known or hereafter developedin all editions, for the life of those editions without restrictionin all languagesin advertisements and promotional materials for the Work.I represent and warrant that (i) I am the sole owner of all copyright, trademark, and other intellectual property and proprietary rights in and to the Material, (ii) Wiley's publication of the Material as authorized herein will not violate or infringe any copyright, trademark, or other intellectual property or proprietary right of any person or entity, and (iii) I am not a party to and the Material is not subject to any contract or arrangement which would conflict with my permission herein.The laws of the country set forth below shall apply to your country of residence, without regard to conflicts of law rules. The corresponding jurisdiction shall be the forum for adjudication of all disputes arising in connection with this agreement:Country of ResidenceApplicable LawAgreed JurisdictionUnited States and all other countries not expressly stated belowState of New YorkNew York, NYUnited Kingdom and EMEA (excluding Germany)England and WalesEngland and WalesCanadaOntarioProvince of OntarioGermanyFederal Republic of GermanyWeinheimAustralia and APAC (excluding Singapore)State of VictoriaMelbourneSingaporeSingaporeSingaporePlease indicate your agreement by signing and returning this form. In signing, you warrant you have no claim on ground of breach of confidence or on any ground in any legal system against Click here to enter text.in respect of the publication of images of, or quotations from, you.*If the subject is under the age of 16, consent should be given by a parent or guardian and the relationship to the subject indicated.I/We hereby grant permission for the use of the material requested above.Name of Subject / Parent / Guardian: .............................................................................Signature of Subject / Parent / Guardian: …………………………………………………………………. Address: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. Date:.........................................Standard release form, v 2.1 (June 2015) ................
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