MEDIA RELEASE FORM
I hereby grant _________________________ (insert name) of
___________________________address, hereinafter referred to as “The Releasee,” the absolute
and irrevocable right and permission, in respect of any Media taken of me, (which includes but is
not limited to photographs, videos and audio) to use, re-use, publish, and re-publish the same in
whole or in part, individually or in conjunction with other Media, and in conjunction with any
printed matter, or electronic matter, in any and all media now or hereafter known, and for any
purpose whatsoever; and to use my name in conjunction therewith if the Releasee so chooses.
I hereby release and discharge the Releasee from any and all claims and demands arising out of
or in connection with the use of the Media, including without limitation any and all claims for
libel or invasion of privacy.
I hereby waive any right to inspect or approve the Media.
This authorization and release shall also inure to the benefit of the heirs, legal representatives,
licensees, and assigns of the Releasee.
I am of full age (18) and have the right to contract in my own name. If I am not yet 18 years of
age, a parent or guardian has authorized my signature. I have read the foregoing and fully
understand the contents thereof.
The release shall be binding upon me and my heirs, legal representatives, and assigns.
Name (print): __________________________________________________________________
Date: __________________ Signature: __________________________________
Phone: _______________________ E-mail: ___________________________________
Witness Name (print):
___________________________________________________________
Date: __________________ Signature: __________________________________
Parent/Guardian Name (print): ___________________________________________________
Date: __________________ Signature: __________________________________
Phone: _______________________ E-mail: ___________________________________
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