Image Consent and Release Form
Programme/Event: 1st Public Health International Conference.
Programme/Event Date: 2nd – 5th April 2022.
Location: Pride inn Paradise, Mombasa Kenya.
Without expectation of compensation or other remuneration, now or in the future, I hereby grant Public Health Officers and Technicians Council, its affiliates and agents who will rely on this image consent and release form, exclusive permission to use my image and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the Internet) for its business (the “Purposes”).
This consent includes, but is not limited to:
- Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
- Permission to use my name;
- Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), and/or any websites that are owned or controlled by Public Health Officers and Technicians Council in theatrical media and/or in mailings for educational and awareness; and
- Permission to store copies of the interview, film, photograph, tape, video reproduction of me and/or voice recording for as long as is necessary to fulfil the Purposes or to Public Health Officers and Technicians Council storing my contact details on its database in case it needs to contact me.
I acknowledge the following:
- This consent is given in perpetuity, and does not require prior approval by me;
- The Recordings and/or Statements may appear on promotional material in conjunction with Public Health Officers and Technicians Council branding and/or any Public Health Officers and Technicians Council business purpose (“Use”).
- I will not be paid for the Use of my Recordings and/or Statements for the Purpose;
- Public Health Officers and Technicians Council will have the right to use all or part of the Recordings and/or Statements alone or in combination with other material and may reasonably adapt or alter my Statements provided the general sense is not changed.
Indemnity Form
This indemnity applies to all persons who enter the premises.
As the visitor I acknowledge that I have read and understand this indemnity and agree to be bound by the following:
- I enter and use the premises, parking areas, surrounds, and stairs on the premises & participate in any activities at the premises entirely at my own risk.
- Right of admission is reserved.
- I warrant that I have been advised and am aware of and accept that I will be exposed to a variety of risks and dangers at the premises which have been explained to me in detail and that I comprehend the risk and the implications thereof.
- Such risks and activities include without limitation the pool as a recreational area.
- I agree to obey at all times any warning notices and instructions given to me.
- I take note that Pride inn Paradise Mombasa and Public Health Officers and Technicians Council -its employees, and agents will not be liable whatsoever for injury, death, property damage, or any other loss sustained during the visit.
I hereby confirm that I have read, understood, and agree to the terms and conditions of the Image Consent and Release form and the Indemnity form.
Name: _______________________________________________
Signature: ____________________________________________
Date: ___________________________________________