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Video Permission & Consent Form - Lee W. Graber

To participate as a nominee in the “Orthodontics Changing Lives” Competition sponsored by the World Federation of Orthodontists (WFO), the patient (or a parent or guardian for nominees under the age of 18) and submitting orthodontist or WFO affiliated organization must agree to the following terms. These terms are a binding agreement under Missouri, U.S.A. law. License Those who have videos and printed text submitted to the World Federation of Orthodontists for the Lee W. Graber Orthodontics Changing Lives Award will retain any intellectual property rights they have in their works, including copyright. This means, for example, they may submit the same work submitted to the WFO to other scholarship programs or contests, keep the work as part of a portfolio, and license it to others for non-exclusive publication. The WFO will not license submitted videos and/or text materials to others. The WFO is granted license to use, copy, publish, publicly or privately exhibit, distribute, or alter the submitted work as required to meet publication media requirements. This license is perpetual, irrevocable, worldwide, royalty-free, transferable, and non-exclusive (with the right to sublicense). The WFO can use the work in any media, including online. The WFO and its representatives will not pay the those submitting or appearing in the video and associated text or their representative(s) for submission or use of the submission. Awardees may be recognized by way of announcements in social and professional media as well as by local recognition within and by the nominating orthodontist’s office. The WFO is granted permission to use the submitting orthodontist’s and patient’s name, photograph or other image if provided, biographical information, and interviews made in connection with the WFO sponsored competition, for information and promotion of WOHD, the Orthodontics Changing Lives Competition and the WFO. The WFO and its representatives will give credit when the submission is used, unless there is a practical reason why the WFO cannot, such as formatting, or if the work is being used in a medium where no individual credits are given. Original Work Requirement All work submitted to the WFO must be original, meaning the submitting orthodontist and/or named patient created the work based on their own ideas. By submitting a video and supporting text to the WFO, the submitting orthodontist, WFO affiliate organization and/or patient (or parents/guardians) agree that they created it and did not copy it from any other 2 person, business, school, online source or organization. Submitted work that infringes upon another’s intellectual property rights will be disqualified. Note to Parents or Guardians of Nominees under the age of 18 A parent or guardian must review and sign this Permission/Consent form for a patient under the age of 18 to be considered. Be sure to read all rules and guidelines to make sure that submissions adhere to WFO guidelines. By way of signature, I agree to the license, permission and consent terms outlined above:

Name of Nominee (Patient’s name):(Required)
Name of Parent or Guardian if Nominee under 18:
MM slash DD slash YYYY
Name of Submitting Orthodontist:
MM slash DD slash YYYY

- OR -

Name of WFO Affiliate Organization Officer:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.