Submit your pictures

    Clinical Simulation Center of Las Vegas
    1001 Shadow Lane, Building B
    Las Vegas, NV 89106-7405
    Main: (702) 774-2150 Fax: (702) 774-2152
    Website: https://csclv.nevada.edu

    Clinical Simulation Center (CSCLV): Audio/Video and Photography Release Form
    One form per picture

    Name:

    Address:

    Phone:

    Email:

    I hereby grant to the Clinical Simulation Center of Las Vegas (CSCLV) and its authorized agents the following rights and permissions with respect to photographs, films, or voice recordings of me, or of materials owned by me (collectively hereinafter the “Materials”):

    • To use, reproduce, edit, publish, and re-publish the Materials for any educational purpose, including, without limitation, web publication, broadcast, illustration, instruction, publicity, marketing, or training.
    • To copyright the Materials under CSCLV’s name or any other name designated by CSCLV.
    • To use my name and likeness in connection with the Materials at CSCLV’s discretion.
    • I acknowledge that the center may choose not to use the Materials at this time, but may do so at its own discretion at a later date.
    • I understand that once the Materials are posted on CSCLV’s website, they can be downloaded by any computer user on or off campus.
    • Furthermore, I acknowledge that CSCLV reserves the right to discontinue use of the Materials without notice.

    In consideration of CSCLV’s support of this opportunity to provide these Materials, and because I am voluntarily providing Materials, I release CSCLV staff and their successors from all claims relating to or in connection with the use of the Materials, whether foreseen or unforeseen, known or unknown, including, without limitation, any claims for negligence, libel, defamation, and any right to publicity or privacy. Further, I agree to the terms set out in this document (the “Release”).

    If under the age of 18:
    Parent of Guardian Name:

    Parent of Guardian Address:

    Parent of Guardian phone:

    Parent of Guardian Email:

    By clicking submit you authorize that the media provided can be distributed on the CSCLV Site if selected.

     

    Media Information

    Desctiption of Media:

    Where it was taken:

    When it was: