Media Release Form

Media Release Form
Name of Releasor or Releasor's Parent or Guardian

First NameLast Name
Athlete or Participant's Name (If different from the Releasor)

First NameLast Name
Date of Release

MonthDayYear
Address of Releasor

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Releasor
Format: (000) 000-0000.
Email of Releasor
example@example.com
Age of Releasor or Releasor's Parent or Guardian
Video UseNewslettersBrochures or FlyersWebsitesOther
CONFORME I, (hereinafter referred to as "Releasor"), grant permission to Tristate Developmental Services (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.
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.
Signature of Releasor or Releasor's Guardian*
Should be Empty: