PROMOTIONAL PHOTO CONSENT AND RELEASE

PROMOTIONAL PHOTO CONSENT AND RELEASE

ALEXANDER TECHNIQUE WITH MELISSA WEBBER
Name *

FIRST NAME LAST NAME
DATE OF BIRTH *

Month Day Year
Date
Age *
PARENT/GUARDIAN (FOR MINORS)
PARENT/GUARDIAN (FOR MINORS)
PHONE *
EMAIL *
example@example.com
Address *

ADDRESS

Street Address Line 2

City State / Province

ZIP CODE
PLEASE READ CAREFULLY BEFORE SIGNING
I grant Melissa Webber permission to use and publish photos/videos *

of myself (or my child/legal custody listed above) in print and electronically. taken by me (or my child/legal custody listed above) in print and electronically.
[I understand and agree that these materials will become the property of Melissa Webber. I authorize Melissa Webber to edit, alter, copy, exhibit, publish, or distribute the photos/videos for promotional, advertising, marketing, and educational purposes related to Alexander Technique. I release and discharge Melissa Webber from any and all claims/liabilities arising out of use of the photos/videos for any lawful purpose such as for publicity, advertising, Web content... I waive my rights to compensation arising or related to the use of the photos/videos.]
I request to

view and approve any photos/videos prior to publication/promotional use [I understand and agree that photos/videos are available to all involved in the photo shoot.] receive photo/video copies involving myself (or my child/legal custody listed above) only allow the use of photos/videos that do not include my recognizable face (or the recognizable face my child/legal custody listed above)
Contact Melissa Webber to terminate the use of the photos/videos at any time [Termination of use may take up to 1 month from initial request. Contact: liss@melissawebber.org AND 219.218.1065 AND any contacts information listed where the photos/videos are displayed]

In the case of minors, Melissa Webber has my permission to use photo/video of my child/legal custody with all the permissions outlined above.
[I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.]

Those under 18 years of age must also have this form signed by a parent or guardian.
PRINTED NAME *
SIGNATURE *

Clear
DATE *

Month Day Year
Date
PARENT/GUARDIAN (PRINTED NAME)
SIGNATURE

Clear
DATE

Month Day Year
Date
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Should be Empty:

PROMOTIONAL PHOTO CONSENT AND RELEASE

PLEASE READ CAREFULLY BEFORE SIGNING

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