City of Edina, Minnesota

SWTV Media Release Form

Authorization for Release of Photographs, Videotape, Audio Recording or Film.

I (we) hereby consent, authorize and assign any and all rights to SWTV, the City of Edina and the Edina Playback Facility, including agents, officers, employees and all other persons or entities to whom release or circulation may be made including news and media organizations (�Organizations�) to use, reproduce, prepare, publish, distribute, transmit, exhibit or broadcast photos, videos, film and audio recordings (whether or not edited, retouched, altered or otherwise changed or modified), any picture, portrait or likeness of me for use in publicity releases in newspapers, for posting on social media sites, broadcasting on television or radio, for use on the City�s website(s) or videos, or any other City publication.

I (we) further consent and authorize the Organizations and others to release or circulate the same in any manner for any and all purposes in any form with or without my name, group or organization or other identification or the names of others covered by this release.

I (we) understand the photos, videos, film and/or audio recordings will be viewed by the general public and that other use may be made of them.

I (we) further agree and consent that the Organizations and others are not responsible for any misappropriation of the photos, videos, film and /or audio recordings by any member of the general public or anyone else. I (we) further agree that the Organizations are not responsible for any harm that may arise from any such misappropriation.

I (we) waive all right of privacy or compensation which I (we) may have in connection with such use of my picture, portrait or likeness by the City.

I (we) have read the foregoing release, authorization and agreement before signing below and I warrant that I (we) fully understand the contents thereof.

Name*

Name of Parent or Guardian (if a Minor)

Date*

Phone*

### ### ####

E-mail

e.g:xyz@mail.com

Policies

Statement of Responsibility

I agree. By checking this box with an �X� and submitting this document electronically, you agree that you have read, understand and will comply with Southwest Suburbs Public Access Channel Cablecast Request Form. I accept full responsibility for all program content and for all claims arising out of the cablecasting of any program I am presenting. I agree to indemnify and hold harmless the City of Edina, identified as �Edina Playback Facility� in the policies and procedures, and its directors, officers, agents and staff; SWSCC, its Commissioners, officers, agents and staff; and Comcast against any such claims arising out of the program I submit or any breach of this statement of compliance. Furthermore, I understand that I may be subject to federal, state, and local laws regarding libel, slander, obscenity, incitement, indecency, unlawful activities, invasions of privacy, copyright or other similar laws.

I have read and agree to the Statement of Responsibility

Data Privacy

The Minnesota Data Privacy Act requires that we inform you of your rights about the private data we are requesting on this form. The following data contained on this form will be considered private data pursuant to M.S. 13.548: the name, address, telephone number, any other data that identifies the individual, and any data that describes the health or medical condition of the individual, family relationships, and living arrangements of an individual or which are opinions as to the makeup or behavior of an individual. We need this data to register you for a program and to contact you if necessary. Edina staff will have access to the data you provide to administer the program. You are not legally required to provide the data; however, refusing to supply the data may cause your registration to not be processed. Your acceptance here indicates you have read and understand these rights.

I have read and agree to the data privacy policy

Authorization for Release of Photographs, Videotape, Audio Recording or Film.

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