SAMI Form – International Institute for Astronautical Sciences

Project PoSSUM, Inc, Integrated Spaceflight Services and/or the International Institute for Astronautical Sciences
IIAS

Project PoSSUM, Inc, Integrated Spaceflight Services and/or the International Institute for Astronautical Sciences request your permission to use your name and likeness in print and electronic format.

I authorize Project PoSSUM, Inc, Integrated Spaceflight Services and/or the International Institute for Astronautical Sciences (collectively, ‘the Parties’) to record and photograph my image and/or voice for use by the Parties, its affiliated researchers, or its assignees in medical, training, research, educational and promotional programs. I understand and agree that these audio, video, film and/or print images may be edited, duplicated, distributed, reproduced, broadcast, and/or reformatted in any form and manner without payment of fees, in perpetuity.

This information is also used for general publicity purposes, which may include but is not limited to: newsletters, brochures, photos to accompany articles sent to other publications, marketing publications, educational publications, and distribution to local news media, video, computer presentations, internet and websites.

I attest that I have received recent clearance from a physician to participate in flight/high altitude related activities, including the appropriate class flight physical, and do not have any condition that is contraindicated to hypobaric exposure. I understand my sinus airways need to be free from any congestion due to colds, sinus infections, etc. in order to experience non-painful hypobaric exposures and I have discussed any other health related matters or concerns with my physician.

I understand and agree for myself, my heirs, executors, administrators and assigned that in the event any claim or course of action shall be prosecuted against the Parties, their officers, instructors, employees, agents, affiliated researchers, or servants (including volunteer crew members and hospital contractors), I shall indemnify, release and hold harmless the same from any and all claims or courses of action by whomever or wherever made or presented.

Authorization*

I acknowledge that I have read and understood and agree to the above statements.

Name*

First Last

Date*

SAMI Photo Release Form