Science as Art Contest Permission/Release Form for Copyrighted Materials (Use multiple copies of form, if necessary) 1. TITLE/DESCRIPTION OF COPYRIGHTED WORK: _________________________________________________________________ 2. TYPE of MATERIAL: MUSIC VIDEO LITERARY (circle one) or Other _________ 3. I, ____________________________________________________, verify that I (print name of copyright holder) am the copyright holder of the material named above and I, hereby, grant permission to: __________________________________________________________________ (print name of Science Learning Center Science as Art entrant) to include the above-named copyrighted work (the Work) in any and all forms, as part of an entry for the Science Learning Center’s Science as Art Contest. I also hereby release and discharge the above-named and the Regents of the University of Michigan from any claims I may have arising out of broadcast, exhibition, publication, promotion or other use of the entry. /s/_____________________________________________ *SIGNATURE (author/copyright holder) Typing your name, following the /s/ shown above, is legally binding and attests to the accuracy of statements provided in this document. ______________________________________________ DATE *Note: If there are multiple copyright holders for one work, each copyright holder of the copyrighted material must provide a signature on a separate permission/release form.
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Science as Art Contest Permission/Release Form for Copyrighted Materials
(Use multiple copies of form, if necessary)
1. TITLE/DESCRIPTION OF COPYRIGHTED WORK:_________________________________________________________________
2. TYPE of MATERIAL: MUSIC VIDEO LITERARY (circle one) or Other _________
3. I, ____________________________________________________, verify that I(print name of copyright holder)
am the copyright holder of the material named above and I, hereby, grantpermission to:__________________________________________________________________
(print name of Science Learning Center Science as Art entrant) to include the above-named copyrighted work (the Work) in any and all forms, aspart of an entry for the Science Learning Center’s Science as Art Contest. I alsohereby release and discharge the above-named and the Regents of theUniversity of Michigan from any claims I may have arising out of broadcast,exhibition, publication, promotion or other use of the entry.
/s/_____________________________________________ *SIGNATURE (author/copyright holder)
Typing your name, following the /s/ shown above, is legally binding and attests to the accuracy of statements provided in this document.
______________________________________________ DATE
*Note: If there are multiple copyright holders for one work, each copyright holder of thecopyrighted material must provide a signature on a separate permission/release form.
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