Picture and Video Image Sample Release Form

RELEASE&FORM&
!
By!signing!this!release!form,!I!authorize![YOUR!ORGANIZATION],!to!use!the!following!personal!
information:!
!
(1)!My!picture!–!including!photographic,!motion!picture,!and!electronic!(video)!images.!
(2)!My!voice!–!including!sound!and!video!recordings.!
!
I!hereby!grant!to![YOUR!ORGANIZATION],!its!subsidiaries,!licensees,!successors!and!assigns,!the!
right!to!use,!publish,!and!reproduce,!for!all!purposes,!my!name,!pictures!of!me!in!film!or!
electronic!(video)!form,!sound!and!video!recordings!of!my!voice,!and!printed!and!electronic!
copy!of!the!information!described!in!sections!(1)!and!(2)!above!in!any!and!all!medi a!in clud in g,!
without!limitation,!cable!and!broadcast!television!and!the!Internet,!and!for!exhibition ,!
distribution,!promotion,!advertising,!sale,!press!conferences,!meetings,!hearings,!educational!
conferences!and!in!brochures!and!other!print!media.!This!permission!extends!to!all!languages,!
media,!formats!and!markets!now!known!or!hereafter!devised.!This!permission!shall!continue!
forever!unless!I!revoke!the!permission!in!writing.!
!
I!further!grant![YOUR!ORGANIZATION]!all!right,!title,!and!interest!that!I!may!have!in!all!finished!
pictures,!negatives,!reproductions,!and!copies!of!the!original!print,!and!further!grant![YOUR!
ORGANIZATION]!the!right!to!give,!sell,!transfer,!and!exhibit!the!print!in!copies!or!facsimiles!
thereof,!for!marketing,!communications,!or!advertising!purposes,!as!it!deems!fit.!
!
I!hereby!waive!the!right!to!receive!any!payment!for!signing!this!release!and!waive!the!right!to!
receive!any!payment!for![YOUR!ORGANIZATION’S]!use!of!any!of!the!material!described!above!
for!any!of!the!purposes!authorized!by!this!release.!I!also!waive!any!right!to!inspect!or!approve!
finished!photographs,!audio,!video,!multimedia,!or!advertising!recordings!and!copy!or!printed!
matter!or!computer!generated!scanned!image!and!other!electronic!media!that!may!be!used!in!
conjunction!therewith!or!to!approve!the!eventual!use!that!it!might!be!applied.!
!
I!acknowledge!that!I!have!read!the!foregoing!and!I!fully!understand!the!contents.!
!
!
IN!WITNESS!WHEREOF,!I!have!executed!this!release!on!this!____!day!of!__________,!2010.!
!
Print!Name:!! ! ! ! ! ! Telephone!Number:!
!
Address:!! ! ! ! ! ! Signature:!
!
City/State/Zip:!
!
!
!
!
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Picture and Video Image Sample Release Form PDF

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