Authorization for Use of Personally Identifiable Information for Media and Marketing Purposes (Minor)

Western Michigan University and the City of Niles

Purpose of this Form

Western Michigan University (WMU), the Fort St. Joseph Archaeological Project, and the City of Niles are committed to protecting the privacy of students’ personally identifiable information (PII)[1]. The Family Educational Rights and Privacy Act (FERPA) gives you protections regarding the use and release of students’ personal information.  This federal law[2] requires that we obtain your/your student’s authorization to disclose this information for the purpose identified below. 

Authorization

• I authorize the Fort St. Joseph Archaeological Project (WMU’s Institute for Intercultural and Anthropological Studies and the City of Niles) to use and discuss my child’s first name and image for marketing and promotional purposes. 
• A copy, fax, or electronic version of this authorization will be as valid as the original.
• I understand that I/my student will receive no monetary compensation for my appearance in any video/production/publication, etc.
• I understand that WMU and the City of Niles cannot control photography and/or filming between students.

Exceptions

• This release does not apply to health records that are protected by the Health Information Portability and Accountability Act (HIPAA). 

Effective Dates and Revocation

This authorization is effective for ten years, or until the Fort St. Joseph Archaeological Project (WMU’s Institute for Intercultural and Anthropological Studies and the City of Niles) is no longer using the interview, testimonial, photograph, or video, whichever comes first. I understand that I may revoke this authorization at any time by submitting a written request to the Fort St. Joseph Archaeological Project. The revocation will not apply to information that has already been disclosed. I understand that, once disclosed, my information may be re-disclosed by a non-WMU entity. 

Waivers

I also release and hold harmless City of Niles, WMU, their representatives, and their delegees from and against any claim for any injury related to use of my child’s image, voice, likeness, name or any other identifying characteristics obtained from the activities identified in this authorization. I further release and hold harmless City of Niles, WMU, their representatives, and their delegees from any and all liability due to alteration of or use of my child’s information in composite form that may occur in the making or processing of said medium.

Although I have the right to a copy of any of my child’s information that is released, I waive any right to inspect and/or approve the finished product that may be used in connection with this authorization.