Networking Differently Registration & Media Release Form

Media Release Form

& Networking Differently Registration
Today's Date

MonthDayYear
Pre-Entered
Name of Releasor*

First NameLast Name
Email*
example@example.com
Birthdate*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Company Name/Affiliation
Address of Releasor

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The Media obtained shall be used for

Video UseEmail blastsNewslettersBrochures or FlyersMagazinesWebsitesSocial MediaOther

CONFORME

I, {nameOf9} (hereinafter referred to as "Releasor"), grants permission to Paul Muffoletto, Alexandra Vileikis, and Paul Muff LLC (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*

Powered by Jotform SignClear
Date*

MonthDayYear
Date Signed
Signature of Releasee

Powered by Jotform SignClear
Date*

MonthDayYear
Date Signed
Should be Empty:

Media Release Form