Video Consent Form

AGREEMENT entered into this day of between Instructor, hereinafter referred to as the Instructor and hereinafter referred to as the Student. WHEREAS, the Instructor is desirous of using videotapes, kinescope, motion pictures and/or photographs of the Student(s) for the purpose of professional education, research, and WHEREAS, the Student, in consideration of the premises, is desirous of endorsing and supporting the use of such videotape, kinescope, motion pictures and/or photographs for the purpose of professional education and research, NOW THEREFORE, it is agreed by the parties hereto as follows:

1. In consideration of the mutual covenants contained herein the Student consents to the use of videotape, kinescope, motion pictures and/or photographs of himself heretofore made or hereinafter to be made by the Instructor. Specifically the Student refers to videotape, kinescope, motion pictures and/or photographs of himself, alone or with others, taken in the multi-purpose laboratory by the Instructor during the courses of PSY443/543,PSY447/547,PSY413/513,PSY414/514. 

2. The Instructor agrees that the said videotape, kinescope, motion pictures and/or photographs will be used solely in the interest of the advancement of mental health programs and for the purpose of professional education or research and will not be used for any other purpose.

3. I agree that the Instructor is to be the sole owner of all rights in and to the said videotape, kinescope, motion pictures and/or photographs for all purposes herein set forth.

4. I understand that I shall receive no financial compensation for the use of such videotape, kinescope, motion pictures or photographs.

5. Video tapes will be used during the semester in which they were made unless special permission is granted from participants for use in educational and research. 

6. A student will not be penalized in anyway should one not agree to be video-taped. It is a persons privilege to waive their privacy rights as provided by this form.

7. There will be no copies of video-tapes made of the class by either students or Instructor unless permission is granted from participants. IN WITNESS WHEREOF, the parties have duly executed this agreement the day and year first above written.