NASA C-3072 Release Form

National
Aeronautics and
Space
Administration

Release Form
For Appearance in Photographs or Other Image-based Media or
Production by or for the NASA Glenn Research Center

John H. Glenn Research Center at Lewis Field
National Aeronautics and Space Administration
21000 Brookpark Road
Cleveland, OH 44135-3191

Dropping In a Microgravity Environment (DIME)
(Description of photographs/digital images.)

To the United States Government, NASA, the Glenn Research Center, its contractors, partners or those acting
with its authority and permission and employees of the United States Government, NASA, the Glenn Research
Center, its contractors, partners or those acting with its authority and permission I hereby:
a. grant the unrestricted right and permission to copyright and use, re-use, publish, and republish
photographic or digital images of me or in which I may be included intact or in part, composite or
distorted in character or form, without restriction as to changes or transformations in conjunction
with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any
and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any
other purpose whatsoever.
b. permit the use of any printed material in connection therewith.
c. release, discharge and agree to save harmless from any liability by virtue of any blurring,
distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise,
that may occur or be produced in the taking of said picture or in any subsequent processing
thereof, as well as any publication thereof, including without limitation any claims for libel or
invasion of privacy.
d.

affirm that I am over the age of 18 and have the right to contract in my own name. I
have read the above authorization, release and agreement, prior to its execution; I fully
understand the contents thereof. This agreement shall be binding upon me and my heirs,
legal representatives and assigns.

OR
e.

affirm that I am the parent or legal guardian for:

Name of the minor subject(s) depicted in the photographs or digital images
and have the right to contract for him/her. I have read the above authorization, release and
agreement, prior to its execution; I fully understand the contents thereof. This agreement
shall be binding upon me and my heirs, legal representatives and assigns and those of the
subject(s) listed above.

Printed name

Address

Signature

City

Date

Phone Number

NASA C-3072 (NOV 10)

State

Zip