Getting Started with Leadership Gwinnett

Please provide the following information to help us get to know you better.

STATE OF GEORGIA, COUNTY OF GWINNETT The undersigned, in consideration of having been selected and agreed to participate in the Leadership Gwinnett Program, by the execution of this document, hereby acknowledges, agrees and covenants the following: The maintaining of confidentiality of all information acquired, opinions expressed and all statements made by me and others during the program is a critical element of the success of the Leadership Gwinnett Program. All statements, written or oral, whether by Leadership Gwinnett participants, speakers, group facilitators, or others, are “off the record” and are not to be published, repeated, or attributed either orally or in writing, by me. Under no circumstances will I discuss information, acquired or statements made during the Leadership Gwinnett Program. I will not make any information, written or verbal, available to any person outside the program. All matters of the Leadership Gwinnett Program are confidential and should in no case be revealed to any unauthorized person. I acknowledge that my keeping the confidences and avoidance of even the appearance of breaching confidence is an important part of my participation of the Leadership Gwinnett Program and the other participants and is a condition of my continued involvement in the Leadership Gwinnett Program. Confidentiality is essential in maintaining the professional reputation and integrity of the Leadership Gwinnett Program. View Confidentiality Agreement PDF

I hereby give Leadership Gwinnett, LLC, its legal representatives and assigns, and those acting with permission of Leadership Gwinnett or employees of Leadership Gwinnett the right and permission to use my name and/or photographs in Leadership Gwinnett’s publications and to copyright and/or use, reuse and/or broadcast and republish still photographs, motions pictures, digital media, videotapes, and/or associated or independent audio recordings of me, or reproductions thereof in color or black and white made through any media, for any purpose whatsoever, including the use of any printed and/or electronic matter in conjunction therewith. Such media may include printed and electronic newsletters, recruiting brochures, magazines, display boards, and the use of my name and/or photographs in electronic versions of the same publications or on the Leadership Gwinnett web site or other electronic forms or media as pertains to Leadership Gwinnett. No permission is given nor implied for the distribution by Leadership Gwinnett of such photographs and names through social media networks unrelated to Leadership Gwinnett. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown. I waive any right to royalties or other compensation that may arise from or related to the use of the photograph(s). I hereby agree to release, defend, and hold harmless Leadership Gwinnett and subordinates, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. In return, Leadership Gwinnett and its subordinates or partners involved with the above media will exercise due diligence and care in the use, display, securing, and maintenance of such items. I understand that I may, at any time, provide written notification to the Leadership Gwinnett President & CEO thereby ending permission for further use of my photographs and/or videos in the above media. This notification cannot, however, guarantee removal of previously prepared and/or in-use materials as described above. I agree to be bound by this release/hold harmless document. View Media Release PDF

My (typed) signature below indicates my agreement to the Confidentiality Agreement and Media Release.

The TYPED SIGNATURE below will serve as my electronic signature. (Please do not insert any other type of digital signature.)