PHOTOGRAPH / PUBLICATION RELEASE

PHOTOGRAPH / PUBLICATION RELEASE
Name *

First Name Last Name
Date of Birth *

Month Day Year
Email *
example@example.com
I authorize Arctic Vision, LLC to use photographs, videos, and/or audio representations of me in publications, literature, brochures, posters, and/or news articles for the purpose of providing information to the public on the services offered by the Arctic Vision, LLC. I understand that confidential information about me will not be disclosed unless I specifically approve of and authorize it in writing. Under the above conditions, I give my permission to use such representations of me in (check all that apply): *

posters/brochures news articles videotapes/television audiotapes/radio educational purposes computerized presentations other
I also understand that I am not obligated to sign this “Photograph / Publication Release” and that, if signed, I may revoke it at any time.
Signature of student *

Clear
Date: *

Month Day Year
Signature of legal guardian *

Clear
Date: *

Month Day Year
Signature of Arctic Vision LLC Staff

Clear
Date:

Month Day Year
Revoked on (date):

Month Day Year
Signature of Client

Clear
Signature of Arctic Vision, LLC Staff

Clear
Date

Month Day Year
Should be Empty: