Contact or visit usKara PetersAssociate Director of Marketing(402) 465-2130kpeters [at] nebrwesleyan.edu (kpeters[at]nebrwesleyan[dot]edu) Photo, Video and Likeness Release Form I hereby consent to and grant permission to Nebraska Wesleyan University the rights to my image, in video, photo, and of the likeness and sound of my voice as recorded on audio or video tape. I understand my image may be edited, copied, exhibited, published, or distributed in a variety of manners. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive any right to royalties or other compensation. Signature Reset Sign above Name Permanent address City State - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone/cell phone Email I acknowledge that I am Over the age of 18 The legal guardian of Submit Leave this field blank