Picture and Video Image Sample Release Form

(If!release!is!provided!on!behalf!of!a!minor:)!
!
I!hereby!certify!that!I!am!the!parent!or!guardian!of!______________,!who!is!under!the!age!of!
eighteen!years,!to!whom!this!release!applies!and!that!I!have!the!legal!authority!to!execute!this!
release.!I!approve!the!foregoing!and!agree!that!we!both!shall!be!bound!thereby.!
Parent/Guardian:!! ! ! ! ! Telephone!Number:!
!
Address:!! ! ! ! ! ! Signature:!
!
City/State/Zip:!
!
Witness:!! ! ! ! ! ! Telephone!Number:!
!
Address:!! ! ! ! ! ! Signature:!
!
City/State/Zip:!
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Picture and Video Image Sample Release Form PDF

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