ORAL HISTORY RELEASE FORM

ORAL HISTORY RELEASE AGREEMENT

Pine Mountain Settlement School Archives & Collections
36 Highway 510, Pine Mountain, Kentucky 40810
Ph: 606-558-3571

Pine Mountain Settlement School collects, preserves and makes accessible materials that document the history and culture of the School and surrounding community. Oral histories, video recordings, various multi-media recordings, and accompanying transcripts, photographic materials and documents provide rich documentation for current and future scholars, genealogists, and researchers.

Your signature on this document indicates your agreement to donate the recording of this oral history as well as any accompanying materials (photographs, documents, transcripts, and any future formats) to Pine Mountain Settlement School to be placed in their permanent collection.

Following your review of the oral history, and your signature on this document, it will be made available for use consistent with the mission of Pine Mountain Settlement School as directed by its Board of Trustees.

Please read this document carefully and indicate any restrictive needs you may have. [For example, request notification of any public use of material.]

Restrictions: ______________________________________________________________________________________________________________________________________________________________________________________________________

I, ___________________________________________________herein permanently donate and convey the
following oral history interview(s) ___________________________________________________________________________________________________and the following materials (if any)  ______________________________________________________, to Pine Mountain Settlement School.

In agreeing to this donation I understand that I am conveying all rights, titles, and interest in the intellectual property to Pine Mountain Settlement School, Pine Mountain, Kentucky. The oral history and any accompanying materials will be available for publication, in both written and digital form. In addition, Pine Mountain Settlement School grants me a nonexclusive license to utilize my interview(s) and/or other material during my lifetime. Further, I grant Pine Mountain Settlement School the right to use my name and likeness in any future publication project.

___________________________________                       ___________________________________________
Interviewee signature                                              Interviewer signature
___________________________________                        ___________________________________________
Interviewee street address                                     Interviewer street address
___________________________________                        ___________________________________________
City, State, Zip code                                                  City, State, Zip code
___________________________________                        ___________________________________________
Date                                                                            Date

GO TO: LIFE HISTORY FORM