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AMERICAN CHEMICAL SOCIETY PERSONAL RELEASE FORM I hereby grant to the American Chemical Society, its affiliates and licensees (collectively referred to as “the Society”), royalty-free permission, including the exclusive worldwide, irrevocable rights in all languages, to reproduce in all formats, including, but not limited to print, microfilm, electronic, and/or CD-ROM, my likeness as shown in the photograph(s) taken of me on this date at the American Chemical Society national meeting (“the photographs”). Further, I hereby waive my right to inspect or approve any copy that is used in connection with the photographs and release and discharge the Society from any and all claims arising out of use by the Society of the photographs for the purposes described above, including any claims for libel and invasion of privacy. I am over the age of twenty-one. I have read the foregoing and fully understand its contents. Signature: ___________________________________________________ Printed Name: ________________________________________________ Date: _________________
If you are a minor under the age of twenty-one, have your parent or guardian complete below: Name of Minor: ________________________________________________ Relationship to Minor: ___________________________________________ Parent/Guardian Signature: _______________________________________ Parent/Guardian Printed Name: ____________________________________ Date: _______________
