ArtWorks Release Form

Support ArtWorks and give pediatric patients access to the healing power of art.

The undersigned hereby authorizes ArtWorks, The Naomi Cohain Foundation, Inc. (“ArtWorks”) to use the name, age, healthcare agency affiliation, and likeness of the participant identified below (“Participant”), including but not limited to as may be captured in photographs, audio, videos, artwork, quotes, and any other material or information provided by or on behalf of Participant, or created by Participant, in connection with ArtWorks’ programs (the “Materials”). Participant hereby releases ArtWorks and any affiliated or related persons or entities from any and all claims and causes of action based upon ArtWorks’ use of the Materials, and grants ArtWorks permission to use, publish, exhibit and/or reproduce the Materials in any manner and in any and all media now known or later developed, without obligation to pay Participant any royalty or compensation of any kind. Such rights include but are not limited to use in connection with advertising, social media, publicity, marketing, fundraising, promotional and other commercial purposes.

Participant also grants ArtWorks a perpetual, royalty free, irrevocable, transferable license to any art, writings or other works of authorship (the “Works”) created by Participant in connection with any ArtWorks program. Such license includes but is not limited to: (i) copyrights; (ii) rights to reproduce, display, perform, sell and distribute the Works or copies thereof, in whole or in part, in any form or medium whatsoever; (iii) moral rights, rights to decide whether and in what manner the Works shall be published, advertised, publicized, performed or exploited; (iv) rights to create derivative works and alter, expand, adapt, modify and make any arrangements of the Works; and (v) all rights to enforce, and to seek and secure any statutory protections, as to the Works, including the collection of damages. The foregoing grant shall be limited to those uses which ArtWorks believes, in its sole and absolute discretion, will further ArtWorks’ mission and purpose. Participant hereby releases ArtWorks from all claims, demands and liabilities whatsoever in connection with the foregoing.

- These terms and conditions create a contract between you and ArtWorks (ArtWorks Release Form). By checking this box, you are confirming your understanding and acceptance of the ArtWorks Release Form. The undersigned certifies that he/she does agree to its terms on behalf of him/herself and/or his/her minor child. The rights granted herein are granted in consideration of participant’s involvement in ArtWorks’ programs and acknowledge that such participation would not be possible without the release and license granted herein.
- IF YOU DO NOT AGREE TO THESE TERMS PLEASE CHECK THIS BOX. The undersigned will agree to foregoing photographs, video and transferable license to any art, writings, or other authorship created by the undersigned or undersigned’s minor child in connection with any ArtWorks program, which shall not be taken or used by ArtWorks. The participant who chooses not to be photographed will still be able to participate fully in any ArtWorks program. ArtWorks will make it a priority to protect the participant and their work from being photographed.
Participant Name*
First Last
Child’s Age*
Please enter a number from 1 to 99.
Parent/Guardian Name*
First Last
Parent/Guardian Signature*
(Parent/Guardian must sign for a child 18 and under. If participant is over 18, he/she may sign)
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email Address*
Date*
MM slash DD slash YYYY
Are you human? (Please answer the math question below)
ArtWorks: 96 Engle Street, Suite 120, Englewood NJ 07631
If you have any questions please contact Esther Jun, Program and Development Coordinator at 201-608-0146 or esther@artworksfoundation.org.