Permission to Record: Release Form Date ____________________

I, _________________________________________, hereby authorize the recording of certain presentations, listed below, for the Center of Southwest Studies, Fort Lewis College.

I authorize the use of such recordings by this and any other libraries and educational institutions for scholarly and educational uses and purposes, including use in classrooms and elsewhere, through any media.  This includes the rights of publication in print and in electronic form, such as placement on the Internet/Web for access by that medium, the right to rebroadcast the presentation(s) or portions thereof on the Internet and in other electronic formats, and permission to transfer the  the recording(s) and/or transcription(s) to future technological mediums.

My permission need [__] / need not [___] be secured prior to publication of any part of their contents by users who are not part of an educational institution, other than that which constitutes fair use under the copyright law of the United States (title 17, United States Code).

I authorize the use of my name and such publicity materials (photographs, biographical data, etc.) as may be needed for the announcement and identification of such presentations and recordings thereof.

It is understood by the College and the undersigned with respect to materials not original with myself which I shall use, that permission for their reproduction resides with the copyright owners.

My authorization for recordings extends to the following events or presentations (please use additional space as needed and have speaker initial):

1.  __________________________________________________________________

2.  __________________________________________________________________
 

Signature of speaker:  ___________________________________________________

Speaker's name printed as he/she wishes it used: _______________________________ 

Speaker's address:    ________________________________________________
                                (street or p.o. box)              (city)                   (state)       (zip)

Speaker's phone number: (____) ______- ___________

Speaker's email address: _________________________________________________

WITNESSED BY: __________________________________     Dated: ___________

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Page last modified: August 31, 2005