General Media Release Form

Production Title ____________________________________

Production Date ___ /___ /___

1) I, the undersigned, hereby authorize David George Visual to photograph me, take
motion pictures of me, take video footage of me, and/or make electronic sound
recordings of me (herein referred to as photographic or electronic reproductions).

2) I authorize the use of any such photographic or electronic reproductions of me for any
purpose, including, but not limited to educational and other public media as may be
deemed appropriate by David George Visual (I understand that I may be identifiable
from such photographic or electronic reproduction)

Agreed and accepted by:

Print Name ______________________________________


Address ______________________________________

City, State, Zip______________________________________


Date _________________

I am signing this form as an individual Yes No /Erase answer that does not apply

I am signing this form as a representative of a group, and have full authority to grant release for
this group Yes No /Erase answer that does not apply

Name of group ______________________________________


I certify that I am the parent or guardian of the individual above, ___________________, a minor
under the age of eighteen years. I hereby agree to assume legal responsibility for his/her
authorizations referred to in this General Media Release.

____________________________________ ________________
Signature of Applicant’s Parent/Guardian Date

____________________________________ (_____)___________________
Address of Parent/Guardian (if different) Phone Number (if different)

City, State, Zip Code