Photo Release Form Format

5
Attachment B
I hereby grant the Department of Labor permission to use my likeness in a photograph in any and
all of its publications, including website entries, without payment or any other consideration.
I understand and agree that these materials will become the property of the Department of Labor
and will not be returned.
I hereby irrevocably authorize the Department of Labor to edit, alter, copy, exhibit, publish or
distribute this photo for purposes of publicizing the Department of Labor’s programs or for any
other lawful purpose. In addition, I waive the right to inspect or approve the finished product,
including written or electronic copy, wherein my likeness appears. Additionally, I waive any right
to royalties or other compensation arising or related to the use of the photograph.
I hereby hold harmless and release and forever discharge the Department of Labor from all claims,
demands, and causes of action which I, my heirs, representatives, executors, administrators, or any
other persons acting on my behalf or on behalf of my estate have or may have by reason of this
authorization.
I am 21 years of age and am competent to contract in my own name. I have read this release
before signing below and I fully understand the contents, meaning, and impact of this release.
_____________________________________________ ________________________
(Signature) (Date)
______________________________________________________ _____________________________
(Printed Name) (Date)
If the person signing is under age 21, there must be consent by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of _________________________, named above,
and do hereby give my consent without reservation to the foregoing on behalf of this person.
___________________________________________ ________________________
(Parent/Guardian’s Signature) (Date)
____________________________________________________________________________________
(Parent/Guardian’s Printed Name)
Photo Release Form
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