Science as Art Contest Permission/Release Form for Copyrighted Materials

(Use multiple copies of form, if necessary)

1. TITLE/DESCRIPTION OF COPYRIGHTED WORK:_________________________________________________________________

2. TYPE of MATERIAL: MUSIC VIDEO LITERARY (circle one) or Other _________

3. I, ____________________________________________________, verify that I(print name of copyright holder)

am the copyright holder of the material named above and I, hereby, grantpermission to:__________________________________________________________________

(print name of Science Learning Center Science as Art entrant) to include the above-named copyrighted work (the Work) in any and all forms, aspart of an entry for the Science Learning Center’s Science as Art Contest. I alsohereby release and discharge the above-named and the Regents of theUniversity of Michigan from any claims I may have arising out of broadcast,exhibition, publication, promotion or other use of the entry.

/s/_____________________________________________ *SIGNATURE (author/copyright holder)

Typing your name, following the /s/ shown above, is legally binding and attests to the accuracy of statements provided in this document.

______________________________________________ DATE

*Note: If there are multiple copyright holders for one work, each copyright holder of thecopyrighted material must provide a signature on a separate permission/release form.