Photo & Video Release Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization and Release
What is your preference regarding the use of your name?
*
I consent to the use of my complete name.
I consent to the use of my first name only.
I consent to the use of my nickname
I consent to the use of my photographs anonymously.
Please check the boxes regarding your preference.
*
I authorize ACME Photo to take my photographs.
I authorize ACME Photo to use my photos on Facebook, Twitter, Instagram, and other social media platforms.
I authorize ACME Photo to edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos all intellectual property rights of the photos belong to ACME Photo.
I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: