Social Media Photo & Video Release Form
Name
*
First Name
Last Name
Birth Date
Please select a month
January
February
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Month
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1
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Day
Please select a year
2026
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Year
Gender
Please Select
Male
Female
N/A
Email
example@example.com
Instagram Handle
example@example.com
Authorization and Release
Please check the boxes regarding your preference.
I authorize Fiat Lux Visuals to take my photographs.
I authorize Fiat Lux Visuals to use my photos on Facebook, Twitter, Instagram, and other social media platforms.
I authorize Fiat Lux Visuals 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 Fiat Lux Visuals.
I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.
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 a nickname
I consent to the use of my photographs anonymously.
Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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