Photo Authorization and Release Form

In consideration for my participation in the programs sponsored by the Iowa Space Grant Consortium (ISGC), I hereby consent and agree the officers, servants, agents, or employees of the ISGC (hereinafter referred to as RELEASEES) may use, reuse, publish and republish my picture or likeness and/or written statements, individually or in conjunction with other photographs or communication from the activity described below, in any manner or form, in any medium for any legitimate purpose, and at any time or place so desired. I release and discharge RELEASEES from any liability I may have arising from any alteration that may occur in the marketing and editing of said production. Furthermore, I agree to indemnify and hold RELEASEES harmless from any liability arising from the use or dissemination of said production due to anything I may have said or communicated in same.


I agree that I am to receive no further consideration other than that already received for any further or future uses by said RELEASEES.


I intend for this agreement to be binding on my heirs, successors, and assigns, and it represents the entire agreement between the RELEASEES and me regarding the matters herein agreed.


Activity description: Scholarship, Fellowship, or Internship; Student Hands-on Experiential Opportunity; Research laboratory participation; State Science & Technology Fair of Iowa (SSTFI); and/or Precollege outreach event.

ISGC Affiliation*

ATTN: If you are a Graduate or Undergraduate student working on a Curriculum Development or Academic Project Grant please select the appropriate UG - Other or Grad- Other.

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Please name the research project you will be or are working on, and which professor, if applicable, is the mentor.

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By submitting this form, I fully authorize this photo release.*

Please upload a completed NASA Media Release Form in the event your picture is submitted to NASA.


NASA Media Release Form. For the NASA media release form for location, you may list the main locations where you expect to take photos. For the date field, list the duration of your project, a.k.a period of performance. For the event name, please provide the name of the ISGC award type you are part of, e.x. Curriculum Development, SHO, Base Program. If you do not know this information, consult your team lead,

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If you have any questions about this form, please contact the ISGC representative.

Hailey Waller 515-294-3106 isgc@iastate.edu www.iaspacegrant.org

Please check the box below to receive a copy of your authorization form.

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