Photo and Video Release Form
Client Information
Full Name of person giving consent
*
First Name
Last Name
Age
*
Email
*
example@example.com
Phone Number
Format: (000) 000-0000.
State
*
Zipcode
*
COMPANY PRODUCTION DETAIL
Must Be Heard Productions LLC
Georgia, 31721
Contact Person
Teresa Ann Heard / Linda Harris
Phone number
229-449-1778
Email
doodlingfordemocracy@gmail.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doodling for Democracy Film
www.doodlingfordemocracy.com
Program/Activity
*
Student Fellowship Program
Art for Advocacy Event
Get out the Vote Event
Film Screening
Speaking Engagement
None Listed
Location of Event (Please complete address section below if location not listed)
*
John Lewis High School - Virginia
Clemson University - South Carolina
Virginia Commonwealth - Virginia
Albany, Ga.
Disability History Symposium - Athens Ga.
NONE LISTED
Location of Program/Event
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Authorization and Release Agreement
I am an adult participant.
*
Yes
No
Adults
*
I allow Must Be Heard Productions LLC, its partners, agents, or contractors to take or capture my photos, videos and art work.
I understand that all photos and videos that will be taken in this activity are owned and copyrighted by Must Be Heard Productions LLC and will not be returned to me.
I understand that I will/ will not receive, nor entitled to any royalties or any monetary compensation in respect to the photo and video footage obtained.
I authorize Must Be Heard Productions LLC, its partners, agents, or contractors to distribute and reproduce the materials for the following purposes: Doodling for Democracy Film, Social Media, Portfolio showcase, advertising, marketing, branding, educational, digital promotions, internet videos, online courses, media, other commercial or non-commercial purposes
I grant Must Be Heard Productions LLC, its partners, agents, or contractors to use my photos and videos on Youtube, Vimeo, Facebook, Twitter, Instagram, and other social media platform.
I understand that the materials taken on this event will be covered with this document only.
I irrevocably authorize Must Be Heard Productions and its partners, agents, affiliates, successors, employees, agents, contractors, its legal representatives or assigns, and all persons functioning under its permission or authority to copy, edit, enhance, crop, or otherwise alter any photo or video for use in publications, Doodling for Democracy Film, Social Media, Portfolio showcase, advertising, marketing, branding, educational, digital promotions, internet videos, online courses, media, other commercial or non-commercial purposes.
I hereby affirm that I am over the age of 18 and have the right to contract in my own name.
I also release and discharge Must Be Heard Productions LLC, its partners, agents, affiliates, successors, employees, agents, contractors, its legal representatives or assigns, and all persons functioning under its permission or authority, or those for whom it is functioning, from any any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any kind or nature, claims for libel or invasion of privacy, known or unknown, which I, and anyone claiming on my behalf of me, may have or claim to have against Releasee in connection with this Release.
I have carefully read and fully understand all provision of this release form and are bounded to it and I am freely knowingly and voluntarily signing.
I have a minor(s) or have guardianship of an adult(s) that would like to participate
*
Yes
No
For minors/ adults with guardianship
*
I allow Must Be Heard Productions LLC, its partners, agents, or contractors to take or capture my minor(s) or adult(s) with guardianship's photos, videos and art work.
I understand that all photos and videos that will be taken in this activity are owned and copyrighted by Must Be Heard Productions LLC and will not be returned to me.
I understand that I will/ will not receive, nor entitled to any royalties or any monetary compensation in respect to the photo and video footage obtained.
I authorize Must Be Heard Productions LLC, its partners, agents, or contractors to distribute and reproduce the materials for the following purposes: Doodling for Democracy Film, Social Media, Portfolio showcase, advertising, marketing, branding, educational, digital promotions, internet videos, online courses, media, other commercial or non-commercial purposes
I grant Must Be Heard Productions LLC, its partners, agents, or contractors to use my minor's or adult's photos and videos on Youtube, Vimeo, Facebook, Twitter, Instagram, and other social media platform.
I understand that the materials taken on this event will be covered with this document only.
I irrevocably authorize Must Be Heard Productions and its partners, agents, affiliates, successors, employees, agents, contractors, its legal representatives or assigns, and all persons functioning under its permission or authority to copy, edit, enhance, crop, or otherwise alter any photo or video for use in publications, Doodling for Democracy Film, Social Media, Portfolio showcase, advertising, marketing, branding, educational, digital promotions, internet videos, online courses, media, other commercial or non-commercial purposes.
I hereby affirm that I am over the age of 18 and have the right to contract for the minor(s) or have guardianship over the adult(s) in which this agreement is made.
If the participant is under 18, I affirm that I am the parent or legal guardian of the minor(s) named below and given permission for the use of the minor(s) image, likeness, voice, and appearance as described above OR if the participant(s) is over 18, I affirm that I am the legal guardian on the adult(s) named below and given permission for the use of the adult(s) image, likeness, voice, and appearance as described above.
I also release and discharge Must Be Heard Productions LLC, its partners, agents, affiliates, successors, employees, agents, contractors, its legal representatives or assigns, and all persons functioning under its permission or authority, or those for whom it is functioning, from any any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any kind or nature, claims for libel or invasion of privacy, known or unknown, which I, and anyone claiming on my behalf of me, may have or claim to have against Releasee in connection with this Release.
I have carefully read and fully understand all provision of this release form and are bounded to it and I am freely knowingly and voluntarily signing.
Name of Minor Or Adult (if applicable)
*
First Name
Last Name
Do you have another minor
*
Yes
No
Name of Minor of Adult (if applicable)
*
First Name
Last Name
Do you have another minor
*
Yes
No
Name of Minor or Adult (if applicable)
*
First Name
Last Name
Signature of Adult/Guardian/Parent
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Title of Art Work or Video Sent (PLEASE COMPLETE SECTION BELOW ONLY IF YOU ARE SUBMITTING ART WORK OR VIDEOS)
Image Description (online submission)
Images Upload (Online Submissions)
Browse Files
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Choose a file
UPLOAD IMAGES ONLY - VIDEO SUBMISSIONS SEND TO DoodlingforDemocracy@gmail.com
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of
Video Upload (Online Submissions)
Browse Files
Drag and drop files here
Choose a file
VIDEO UPLOADS
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of
Submit
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