Information and Consent Form

Information and Consent Form<= /o:p>

For valuable consideratio= n, I do hereby authorize Anupama M= ande, professor of history at Fullerton College, and those acting pursuant to the autho= rity of Fullerton College to:

a. Record my participation and appeara= nce on video, audio tape, film, photograph or any other medium.

b. Use my name, likeness, voice and biographical material in connection with these recordings.

c. Exhibit or distribute such recording using their course web site, or other mechanisms, in whole or in part witho= ut restrictions or limitation for any educational purpose which Anupama Mande, professor = of history, and those acting pursuant to the authority of Fullerton College, deem appropriate.

d. To publish under Creative Commons t= he same in its name or any other name it may choose.

I hereby release and disc= harge Anupama Mande, professor = of history, at Fullerton College, from any a= nd all claims and demands arising out of or in connection with the use of such photographs, video, film or tape, including but not limited to any claims f= or defamation or invasion of privacy.

I hereby consent to the r= elease of said video tape, audio tape, film, photograph or any other medium for the above-stated purposes and in accordance with the terms stated above, pursua= nt to the consent provisions of the Family Educational Rights and Privacy Act,= 20 U.S.C. 1232 et.seq.

Name:

Address:

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Signature:

Parent/Guardian

Signature (if under 18): =

Date: