The University of Texas at Austin Photo, Video and Audio Release

I authorize The University of Texas, and those acting pursuant to its authority to:

a. Record participation by myself and my guest(s) in any audio or video format.

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

c. Exhibit or distribute such recording in whole or part without restrictions or limitation for any educational or promotional purpose which The University of Texas, and those acting pursuant to its authority, deem appropriate.

Name:

____________________________________________________________

Address:

____________________________________________________________

____________________________________________________________

Phone Number:

____________________________________________________________

Signature:

____________________________________________________________

Parent/Guardian Signature (if under 18) :

____________________________________________________________

Date :

____________________________________________________________