Likeness Release Form

The undersigned hereby irrevocably consents to and authorizes the use by Missouri State University, its officers and employees, ("University") of the undersigned's image, voice, and/or likeness as follows:

The University shall have the right to photograph, publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse the undersigned's image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed in University's products or services, as long as there is no intent to use the image, voice and/or likeness in a disparaging manner.

University may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or nonprofit.

The undersigned acknowledges receipt of good and valuable consideration in exchange for this Release, which may simply be the opportunity to represent the University in its promotional and advertising materials as described above.

Name Name First Last
M#
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date Date / MM / DD YYYY
Please attach one photo of yourself.

Attach Files

This photo will be used for purposes including for our team's reference when searching for images to be used in publications which require a Likeness Release on file.
Please indicate your agreement to the foregoing by signing below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Select the option that applies to you:

Select the option that applies to you: Student Staff
Select all that apply to you:

Select all that apply to you: I am a transfer student. I am a graduate student. I am a local student (lives close to Springfield). I was a part of the 6-week trial housing program. I have lived on campus for 4 years. I lived on campus, moved off, and moved back on. None of the above.
Please list the residence halls you have lived in.
Tell us about your decision to live on campus.
Tell us about your decision to try 6-week trial housing.
Tell us about your decision to continue living on campus.
Tell us about your decision to move back on campus.
Please give a positive overall quote about any of the residence halls you've lived in, as well as your overall experience living on campus.

This quote may be used in materials promoting Missouri State University and/or the Residence Life, Housing and Dining Services departments. By providing a quote, you are agreeing to allow its use in promotional materials. This field is not required.
Please give a positive overall quote about your experience living on-campus.

This quote may be used in materials promoting Missouri State University and/or the Residence Life, Housing and Dining Services departments. By providing a quote, you are agreeing to allow its use in promotional materials. This field is not required.
Please give a positive overall quote specifically about one or two of the Residence Halls you have lived in on-campus.

This quote may be used in materials promoting Missouri State University and/or the Residence Life, Housing and Dining Services departments. By providing a quote, you are agreeing to allow its use in promotional materials. This field is not required.
What three words would you use to describe your experience living on campus? (Optional)
What is your position in Residence Life?
Please share a few sentences about why you enjoy working at Missouri State University/Residence Life.
Thank you!
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Attach Files

Likeness Release Form

Likeness Release Form

Thank you!