ࡱ> 463k bjbjZ Z * 8cb8cb 8?[$0$u!444Irԇ(_0,)")")"<44)" : SUBJECT PHOTO WAIVER Photographer (Name): ___________________________________________________________ Address: ______________________________________________________________________ Phone : ___________________________ Email:____________________________________ To be completed by the photographer: Photo Number or Title (in logbook): ________________________________________________ Date of Photo: ______________________Location of Photo: ___________________________ Intended Use for Photo: Potential submittal to a study being conducted by a at ݮ. Image could be used in [PI should detail how the photo would be used for research (e.g., facilitate interview, focus groups, etc.). PI should also detail if and how photo might be used in scholarship (e.g., dissertation, thesis conference presentations, articles, websites, instructional materials).] To be completed by the subject: Subjects Name: ________________________________________________________________ Address: ______________________________________________________________________ Phone: ___________________________ Email:____________________________________ I, the subject of this photo, grant you, the photographer, and the affiliated researcher, , use of the photo for the study for which it was taken, subject to the following conditions: [PI should detail how the photo would be used for research (e.g., facilitate interview, focus groups, etc.). PI. Should detail if and how photo might be used in scholarship (e.g., dissertation, thesis conference presentations, articles, websites, instructional materials).] I acknowledge that by signing this form, subject to the usage restrictions above, the photographer has all rights to copyright and may give permission for the photo to be used in a public forum or public research document. I also acknowledge that an audience member or reader of such documents might recognize me. 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