I, the undersigned _____________________________________________, born ______________________ on______________, and residing in____________________, Via/Piazza ________________________ n. _______, with reference to the photographic and/or video footage of my own image as well as audio recordings made as part of the multi-sensory experience “Keil Space”, occurred in Viale Michelangiolo 5, Florence,


that I have read the “Privacy Policy” on the Site for the processing of personal and sensitive data and


in favor of Samantha Keil and the Site to acquire and use, publish and publicize, directly or through third parties, the images/videos, video/audio transcripts and audio recordings depicting me in the Keil Space and related multi-sensory experience, without limitation of modality (e.g. web, social, radio, media, television, data analytics software analysis processes, etc.), time and space, in Italy and abroad, with any and all broader faculty of adaptation and editing as may be deemed necessary/appropriate. The undersigned, having acknowledged the above, declare to have no claim against Samantha Keil for any kind of prejudicial use of the images/videos by third parties.

The right of Samantha Keil to use the images, photographs, videos, recordings as specified above is intended to be free of charge with express waiver of any and all claims in this regard.


Florence, ____

Signature: _________________________



Samantha Keil guarantees that the publication of the images/videos depicting the person concerned will not be detrimental to the honor, reputation and dignity of the same and will be used exclusively for the above purposes and in full compliance with current privacy regulations.