Speaker Release Form

This form is provided to you as a speaker in a course, seminar, lecture, or other presentation at Connecticut Pharmacists Association (CPA). CPA would like to capture your presentation in audio and/or video format. To that end, we want to make certain that both you and CPA have the necessary rights and protections to continue to benefit from your presentation.

CPA will hold the copyright to the Recording and would like to have the option to continue to use the Recording and Materials. In addition to creating an archive copy for educational purposes, possible uses of the Recording include, but are not limited to, inclusion in CPA websites, the creation of CDs or DVDs, and delivery to the public via distribution partners.

Finally, please understand that there is nothing in this Speaker Release requiring you to give your ideas to CPA. If you plan to give the same talk somewhere else, there is certainly nothing in this release that would keep you from that engagement. And, unless there is an exceptional reason, CPA is happy to provide a copy of the Recording to you and will grant you a non-exclusive license to use the Recording in any way you’d like.

Information About You

Name *

First

Last

Title

Institution *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Information About Your Presentation

Presentation Title *

Presentation Date *

Presentation Location (can be virtual) *

Check each of the boxes to agree to the conditions of this release *

I give permission to Connecticut Pharmacists Association to capture my presentation identified above.
I give CPA permission to use my name, likeness and biographic information to use, promote or exploit the Recording or any derivative work of the Recording.
I acknowledge that CPA, in capturing my presentation, will become the copyright owner of the Recording. To the extent I have any rights in the Recording, I hereby assign all my rights, title and interests in and to the Recording to CPA.
I understand that possible uses of the Recording by CPA include, but are not limited to, inclusion in CPA websites, the creation of CDs or DVDs, and delivery to the public via distribution partners.
I understand that CPA grants me the nonexclusive right to exploit the Recording in any manner. I understand that I have the right to ask CPA to provide me a copy.
I acknowledge that this Release is governed by Connecticut law and is a legally binding agreement.
I verify that I have authority to enter into this agreement and that I will be bound by its terms.

Signature *

Date / Time *