Release #: Release Number
Date(s) of production(s): Dates of Production
Photographer name:Name of Photographer
Model: Name of Model
Address: Address of Model
Phone No: Model Phone Number
Model’s Age (at time of production): Model's Age
Model’s Ethnicity: Model's Ethnicity
Parent/Guardian Name: Parent/Guardian Name
Parent/Guardian Email address: Parent/Guardian Email Address
Parent or Guardian phone (if differs from minor): Parent/Guardian Phone
Witness Name: Witness Name
Description of production(s): Production Description
In consideration of the engagement as a model of the minor named above, and for other good and valuable consideration of Description of Further Consideration, herein acknowledged as received, upon the terms hereinafter stated, I hereby grant to Name of Photographer (“Photographer”), his/her legal representatives and assigns, those for whom Photographer is acting, and those acting with his/her authority and permission, the absolute right and permission to take, use, reuse, publish, and republish photographic portraits or pictures of the minor or in which the minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with the minor’s own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising, trade, or any other purpose whatsoever. I also consent to the use of any published matter in conjunction therewith.
I hereby waive any right that I or the minor may have to inspect or approve the finished product or products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied.
I hereby release, discharge, and agree to save harmless and defend Photographer, his/her legal representatives or assigns, and all persons acting under his/her permission or authority or those for whom he/she is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or violation of any right of publicity or privacy.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents thereof.
This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns.