Photo Release_Architectural Heritage Center

1. Permission to Use Photograph

Project: Black Domain

Photographer: Intisar Abioto

Institution: Architectural Heritage Center

I grant to Intisar Abioto ("Photographer") and her legal representatives and assigns, the right to use, exhibit, and publish photographs of me taken for the project Black Domain. I authorize the Architectural Heritage Center ["Institution"], its assigns and transferees to use, exhibit, and publish said photographs in print and/or electronically. I hereby release Photographer, Institution, and their legal representatives and assigns from all claims and liability relating to said photographs. I agree that the Architectural Heritage Center may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content with appropriate image credit. The Architectural Heritage Center will not use my photograph as content or promotion other than for purposes of the abovementioned project.

I have read and understand the above:

Signature*

Printed name*

Organization name (if applicable)

Address (street, city, state, zip)

Phone

Format: (000) 000-0000.

Email

example@example.com

Date*

Date

Signature, parent or guardian (if under age 18)*

2. Photo Caption - Please print below how you wish your name, title, and property to appear in the caption that accompanies your photographic portrait on public display in the Architectural Heritage Center galleries.

Name(s)*

Title/profession/other personal identifier

Photographed property name (if applicable)

The year the photographed property was built

I grant permission include the property address in the photo caption.I do not grant permission to include the property address in the photo caption.

Photographed property address/location

3. Thank you!

An honorariumA printI don't wish to receive either

Please mail the honorarium check or the print to:

Name

Mailing address (street, city, state, zip)

Phone

Format: (000) 000-0000.

Email

example@example.com