ࡱ> GJF 0}1bjbj =4__ OOOcccc4$cj%%%%2 uwwwwww$!$p-Oj"%%E.8%O%uu7BY Fa0,$R.$&$OH@$ : OCCIDENTAL COLLEGE PROJECT INFORMATION AND INFORMED CONSENT FORM FOR DOCUMENTARY MEDIA PROJECTS Red text provides guidance in preparing form. Please delete from your completed form! Faculty Supervisor Name and Contact (phone and e-mail):  FORMTEXT        FILLIN \* MERGEFORMAT Student Producer Name and Contact (phone and e-mail):  FORMTEXT       PRODUCTION TITLE:  FORMTEXT       I acknowledge that on  FORMTEXT      , I was informed by (student producer)  FORMTEXT       of Occidental College of a media project having to do with the following, the way it will be conducted, and the conditions of my participation in it:  In consideration of my participation in the media project identified above, I, the undersigned, do hereby expressly and irrevocably consent to be photographed and/or recorded. I agree that Occidental or the student/faculty producers in question will own any and all rights in said photography and/or recording, and I waive any and all uses of my image, name, likeness, voice, or character including but not limited to, the right to reproduce, distribute, sell, transmit, publish, print, broadcast, exhibit, or otherwise use the above titled production or any portion thereof. I understand that in proceeding with said photography/recording, and the student/faculty producers are doing so in full reliance on the foregoing permission. I release any and all rights, title, or property interest I may have in the production, or so much of it as pertains to me. I understand I shall receive no compensation for my appearance and participation in the media project being produced. Further I agree to hold the student/faculty producers, , its contractors, agents, and employees harmless against any liability, loss, or damage (including reasonable attorneys fees) caused by or arising from the production, exhibition, or distribution of my appearance in the production, or any utterance made by me in connection of my appearance therein. I am at least eighteen years of age, fully aware of the nature and extent of my participation in this project, and have been informed of the possible risks involved in or arising from it. I understand that I may withdraw my participation in this project at any time during filming without prejudice or penalty of any kind. I hereby agree to participate in the project. NAME (Print) __________________________________________________________________ HOME ADDRESS: ______________________________________________________________ PHONE: ______________________________ DATE: _________________________________ SIGNATURE:__________________________________________________________________ Provide two copies of this form: the participant should sign and return to the student, and keep the second for their records. Be sure to have all project information sheets/release forms approved by your faculty supervisor before any shooting occurs. Note that projects involving protected categories of subjects, confidentiality, safety, cultural specificity, deception, or any desire to propose alternate methods of informed consent and release than this form are subject to HSRRC approval at , requiring you to complete and submit the APPROVAL REQUEST FORM FOR MEDIA PROJECTS INVOLVING HUMAN SUBJECTS available on the HSRRC Website in consultation with your Faculty Supervisor. Project Information Sheet Material Here: Write in paragraph form as though you were speaking informally to someone, emphasizing simplicity and clarity. Try to keep the material as short as possible without sacrificing necessary content. This entire form (project info, legal text, and signatures) should fit onto one double-sided photocopy. This will minimize the amount of paperwork you have to provide to a subject. This project information section will need to be translated into the languages of relevance for the communities in which you will be recording. Purpose and objective of the project? (a concise 1-2 sentence synopsis) Why is this documentary important? Why should individuals let you into their space or lives for the world to see? Are there any reasonably expected benefits to participants or their community? What is participation going to entail? Where will the recording take place? What parts of participants lives do you seek to access? How long will it take? What risks and rights are associated with participation? Unless otherwise negotiated, the following need to be made clear: a) participation is voluntary b) participants will not receive compensation for participation c) participants can choose not to answer any questions d) participants can withdraw from participation at any time during the interview. e) the project is intended for public exhibition. Where is the piece going to be exhibited? Underscore that the piece will be screened publicly, and be specific. On campus, streaming online,  l n p  > @ P ` b ǶϜϊϜϜςshTs&jhaMhQB*CJUaJphhcghQCJaJhaMhQB*CJaJphh_CJaJ#jh_qhQCJUaJjhGhQCJUaJhaMhQCJaJ hcghQ6B*CJaJphhQCJaJhGhQCJaJh^ hQ56>*B*phh^ hQ56B*phhQh5-n p " 7$8$H$gdQ $7$8$H$a$gdQ    N P d f h r t v ʻʩʚ}kccWKW?cjhQCJUaJh_B*CJaJphhQB*CJaJphhQCJaJ"jh_CJUaJmHnHu#jzhGh_CJUaJhGh_CJaJjhGh_CJUaJ#jhGhQCJUaJjhGhQCJUaJhGhQCJaJ&jhaMhQB*CJUaJph,jjhaMhQB*CJUaJph  = !12ǼǼǼǛwfU h_hQ6B*CJaJph h_h_6B*CJaJphh_6CJaJhDh_CJaJh_CJaJhv;B*phhv;B*CJaJph(jhGhR6CJUaJmHnHuhGhQCJaJhQCJaJ"jhQCJUaJmHnHujhQCJUaJ#jh_qhQCJUaJ!  !gdv; [$\$gdv; 7$8$H$gdQ12 7$8$H$gd  7$8$H$gdQ7$gd_$.dh7$8$H$].^a$gd_$.dh].a$gd_$.dh].^a$gd_$.dh].a$gdv;'Q PBTaϿ޳xjYjQ@ hcghQ6B*CJaJphhQCJaJ hl+h 6B*CJaJphh 6B*CJaJph hh 6B*CJaJphhh 6B*CJphh 6B*CJphhcgh 6B*CJphhQ6B*CJphh_hQ6>*B*CJphh_hQ6B*CJph h_hQ6B*CJaJph h_h_6B*CJaJph76e ]su tv~00000000 1;1Y1֢h^ hQB*CJaJphhQB*CJaJph h^ hQ6B*CJaJphUhcghQ6>*B*CJph hcghQ6B*CJaJphh^ hQ6B*CJphhQ6B*CJphhcghQ6B*CJph5tuQ  :000y1z1{1|1}1 7$8$H$gdQ^gdQ*^*gdQgdQat film festivals? Dont limit the possible venues if you hope to show it more broadly in the future. It will be very difficult to secure future permissions down the road. Whom should participants contact with questions? Reiterate that you and the faculty advisor are available to answer any further questions or concerns about the project via the contact info provided. 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