Model Release Form
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Release:
I agree to grant the following rights to Bernes Inc, Southland Dental Care, Office of Dr. Delaram Hanookai, DDS, MS Periodontist & Dental Implant Specialist, GK Marketing, who have irrevocable, perpetual and unrestricted rights and permissions to take, use, re-use, publish and re-publish photograph portraits and video of me or in which I may be included without restrictions as to changes or alterations or reproductions thereof for the purpose of website, email, social media and all promotional materials for Bernes Inc, Southland Dental Care, Office of Dr. Delaram Hanookai, DDS, MS Periodontist & Dental Implant Specialist, and GK Marketing. I hereby warrant that I have the right to contract in my own name. I have read the above authorization, release and agreement prior to its execution and I am fully familiar with the contents of this document.
Signature
*
Please Sign your name.
Submit
Should be Empty: