Media Release Form
Date
-
Month
-
Day
Year
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
Email blasts
Newsletters
Brochures or Flyers
Magazines
Websites
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Agreed and Accepted by
Name of Releasee
First Name
Last Name
Email of Releasee
example@example.com
Phone Number of Releasee
-
Area Code
Phone Number
Age of Releasee
Address of Releasee
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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CONFORME
I, {nameOf9} (hereinafter referred to as "Releasor"), grants permission to {nameOf} (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
Submit
Should be Empty: