The Aga Khan Museum - School Visit Booking Form

Poetry Release Form

Name of Event(Required)

Date(Required)

Please indicate your compliance with the statement below.(Required)

I acknowledge that the poem developed as part of the Nuit Blanche Poems in Passage Bespoke Poetry Station will be used by the Aga Khan Museum for educational, promotional and display purposes. I voluntarily grant the Aga Khan Museum, and representatives and agents, in connection with the poem that I have jointly created with the Poems in Passage team, consent and permission to use, re-use, publish and re-publish the said poem, in whole or in part, individually or in conjunction with other content, photographs, videos, and audio for educational, promotional and display purposes by any currently known or subsequently discovered means without restriction as to alteration.

Please indicate your compliance with the statement below.(Required)

I acknowledge that no money has been tendered nor promised to me for the consent to use the said poem and that my consent is given in perpetuity and for no financial compensation.

Please indicate your compliance with the statement below.(Required)

I hereby release Aga Khan Museum, the Aga Khan Development Network, and each of their respective officers, directors, members, assignees, licensees, representatives, agents and employees and all those for whom they are responsible in law harmless from and against all claims and losses arising in connection with or resulting from any liability arising out of or in connection with the use of the said poem. Those for whom it is responsible by law and/or all contributors to the above noted content, breach or alleged breach of any agreements, representations or warranties under this Release.

Please check ONE BOX BELOW:(Required)

I am 18 years of age and have read the foregoing and fully understand the contents thereof.

I am the authorized guardian/agent of the poetry participant. I have read the foregoing and fully understand the contents thereof.

Name of Participant, Guardian, or Authorizing Party(Required)

First Last

By entering my name in the field above I acknowledge this acts as a signature to give consent under the terms above.

Email(Required)

Phone(Required)

Site Navigation

Nuit Blanche Poetry Release Form

Poetry Release Form