LEECH LAKE TRl-AL COLLEGE Gaa-za g askwaa j imekaa g Gabe- g ikendaasowi g ami g Multimedia Participant REVERSAL of CONSENT Form Complete this form and turn into Student Services or Multimedia Office if you are reversing your consent to appear in various Leech Lake Tribal College multimedia publications. "I Do Not grant permission or consent for the Leech Lake Tribal College and its successors and assignees the right to record, use, reproduce, livestream, and distribute my voice, image, name, writings, photos, videos, and art work in multimedia productions for educational, publication, or marketing purposes at Leech Lake Tribal College. The form must be accompanied by a current photo of the student and must be renewed each year in order to be valid (this form is effective for one year July 1st-June 30th). " Please be advised that: 1. Images and videos taken in public spaces and/or at public events do not require authorization for publication. 2. It is your responsibility to notify personnel you have signed the Multimedia Participant Reversal of Consent Form. I state that I am at least 18 years of age and am competent to contract in my name. A parent or guardian must sign for all participants under the age of 18. I have read and understand this Multimedia Participant Reversal of CONSENT FORM and acknowledge that it is firm and final and that Leech Lake Tribal College may proceed in reliance thereon. SIGNATURE: DATE: PRINTED NAME: LLTC: Student Faculty Staff Alumni Other E-MAIL: _____________________________________ PHONE: ______________________________________ ADDRESS: -------------------------------- CITY: STATE & ZIP: ------------- FOR PARTICIPANTS UNDER 18 YEARS OLD PARENT/GUARDIAN'S SIGNATURE: ------------------- PRINTED NAME: ------------------- DATE: ------------------- PLEASE RETURN THIS FORM WITH A CURRENT PHOTO (FOR IDENTIFICATION PURPOSES ONLY) TO Leech Lake Tribal College Multimedia Office, 6945 Little Wolf Road, Cass Lake, MN 56633 Cedar Hall Room 210i Phone: (218) 355-4229 e-mail: [email protected] www.lltc.edu 12.20.2018 This form does not pertain to LLTC security cameras, security cameras will continue to be used for everyone safety and security on campus.

Multimedia Participant REVERSAL CONSENT F...Leech Lake Tribal College Multimedia Office, 6945 Little Wolf Road, Cass Lake, MN 56633 Cedar Hall Room 210i Phone: (218) 355-4229 e-mail:

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Page 1: Multimedia Participant REVERSAL CONSENT F...Leech Lake Tribal College Multimedia Office, 6945 Little Wolf Road, Cass Lake, MN 56633 Cedar Hall Room 210i Phone: (218) 355-4229 e-mail:

LEECH LAKE TRl13AL COLLEGE Gaa-zagaskwaajimekaag Gabe-gikendaasowigamig

Multimedia Participant REVERSAL of CONSENT Form

Complete this form and turn into Student Services or Multimedia Office if you are reversing your consent to appear in various Leech Lake Tribal College multimedia publications.

"I Do Not grant permission or consent for the Leech Lake Tribal College and its successors and assignees the right to record, use, reproduce, livestream, and distribute my voice, image, name, writings, photos, videos, and art work in multimedia productions for educational, publication, or marketing purposes at Leech Lake Tribal College. The form must be accompanied by a current photo of the student and must be renewed each year in order to be valid (this form is effective for one year July 1st-June 30th). "

Please be advised that:1. Images and videos taken in public spaces and/or at public events do not require authorization forpublication.2. It is your responsibility to notify personnel you have signed the Multimedia Participant Reversalof Consent Form.

I state that I am at least 18 years of age and am competent to contract in my name. A parent or guardian must sign for all participants under the age of 18.

I have read and understand this Multimedia Participant Reversal of CONSENT FORM and acknowledge that it is firm and final and that Leech Lake Tribal College may proceed in reliance thereon.

SIGNATURE: DATE:

PRINTED NAME: LLTC: Student Faculty Staff Alumni Other

E-MAIL: _____________________________________ PHONE: ______________________________________

ADDRESS: --------------------------------

CITY: STATE & ZIP:-------------

FOR PARTICIPANTS UNDER 18 YEARS OLD

PARENT/GUARDIAN'S SIGNATURE:-------------------

PRINTED NAME:-------------------

DATE:-------------------

PLEASE RETURN THIS FORM WITH A CURRENT PHOTO (FOR IDENTIFICATION PURPOSES ONLY) TO

Leech Lake Tribal College Multimedia Office, 6945 Little Wolf Road, Cass Lake, MN 56633 Cedar Hall Room 210i Phone: (218) 355-4229 e-mail: [email protected] www.lltc.edu

12.20.2018This form does not pertain to LLTC security cameras, security cameras will continue to be used for everyone safety and security on campus.