Media Release Form

Media Release Form
Date*

MonthDayYear
Date
Name of Releasor/ Responsible Party*

First NameLast Name
Email of Releasor*
example@example.com
Phone Number of Releasor*
Select Type of Media*

Video UseAudioPhotoOther
Description of What We Have Permission to Use*
I agree that Grace Givers has my permission to use my image/audio/video publicly for the needs of Grace Givers Home Care LLC. I understand that the item released 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.

I likewise understand that I may be identifiable from the reproduction of the media by Grace Givers Home Care LLC.

I hereby waive my rights to inspect or approve the media for production that may be used by Grace Givers Home Care LLC 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 item.
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.
Date*

MonthDayYear
Date
Signature of Releasor or Responsible Party*

Clear