Photography & Video Release Form

Photography & Video Release Form

Double Tap Media: 517 Leesville Rd, Suite 202, Lynchburg, VA 24502
Model Contact Information
Your Full Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization
I grant permission to Double Tap Media and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, stock photography, or stock video, in any manner or in any medium.

I hereby release Double Tap Media and its legal representatives of all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.
To signify your agreement with the above statement, sign your name below.*

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Model Contact Information