Media Release Form

Date

Name of Releasor

First Name Last Name

Email of Releasor

example@example.com

Phone Number of Releasor

Area Code Phone Number

Age of Releasor

Address of Releasor

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

The Media obtained shall be used for

Video Use Newsletters Brochures or Flyers Websites

CONFORME I, {nameOf9} (hereinafter referred to as "Releasor"), grants permission to Tristate Developmental Services (hereinafter referred to as "Releasee"), to use my media (photograph image and/or video footage and/or audio recordings). I likewise understand that I may be identifiable from the reproduction of the media by the Releasee indicated herein this agreement. I hereby waive my rights to inspect or approve the media for production that may be used by the Releasee for purposes stated herein, from hereon forward. I likewise waive any right to royalties or any compensation arising from or related to the use of the image.

Attestation of Legal Age

I certify that I am of legal age and competent to contract in my own name. I have read this release before signing below and I fully understand the contents, terms, and the effect of this release.

Attestation of Parent/Guardian

I am the parent or legal guardian of the named minor in this agreement. I have read this release before signing below, and I fully understand the contents, terms, and the effect of this release.

Signature of Releasor or Releasor's Guardian *

Clear