Page 1 of 1

Potekglass Publicity Consent and Class Release

Photo and Video Release
I, the undersigned, hereby grant permission to Potekglass, its representatives, employees, agents, and affiliates, to take photographs and/or video recordings of me (or my child, if under 18) and to use these images in any and all media, including but not limited to printed publications, digital content, websites, and social media platforms.
I understand that:
o The images or video may be used for promotional, educational, or informational purposes.
o I will not receive compensation for the use of the images.
o All rights, title, and interest in the photos/videos belong to Potekglass
o I may withdraw consent at any time by providing written notice to Potekglass.
Class Release
The following release is entered into by the undersigned in conjunction with an educational seminar being attended by the undersigned and conducted by Malcom Potek & Potekglass.
The undersigned hereby releases Malcom Potek, his agents and successors from any and all claims arising out of or related to any seminar, class or educational forum conducted by Malcom Potek. The undersigned acknowledges that working with glass, propane, oxygen, and torches have inherent risks, that the undersigned understands the risks, and the undersigned assumes responsibility for such risks.
By typing my name in the box below, I consent to the Photo and Video Release and Class Release written above, and I understand and agree that all electronic signatures are the legal equivalent of my handwritten signature.

Name of Participant (Electronic Signature):

Name of Person Who Registered (If Different Than Yourself)

Is Participant Under 18?

Today's Date

Address

Address Line 2

City

State/Province

Postal/Zip Code

Email

Phone Number

Class or Event Name

Class Date or First Day of Class

Thank you! We look forward to seeing you in class!