MODEL RELEASE / AUTHORIZATION TO
PHOTOGRAPH
In consideration of my engagement as a
model, upon the terms herewith stated, I hereby give to
_________________________, his heirs, legal representatives and assigns, those
for whom _________________________ is acting, and those acting with his/her
authority and permission:
a) the unrestricted right and permission
to copyright and use, re-use, publish, and republish photographic portraits or
pictures of me or in which I may be included intact or in part, composite or
distorted in character or form, without restriction as to changes or
transformations in conjunction with my own or a fictitious name, or
reproduction hereof in color or otherwise, made through any and all media now
or hereafter known for illustration, art, promotion, advertising, trade, or any
other purpose whatsoever.
b) I also permit the use of any printed
material in connection therewith.
c) I hereby relinquish any right that I
may have to examine or approve the completed product or products or the
advertising copy or printed matter that may be used in conjunction therewith or
the use to which it may be applied.
d) I hereby release, discharge and agree
to save harmless _________________________, his/her heirs, legal
representatives or assigns, and all persons functioning under his/her
permission or authority, or those for whom he/she is functioning, 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 invasion of privacy.
e) I hereby affirm that I am over the age
of majority and have the right to contract in my own name. I have read the
above authorization, release and agreement, prior to its execution; I fully
understand the contents thereof. This agreement shall be binding upon me and my
heirs, legal representatives and assigns.
Dated: ________________Signed:
______________________________________
Address:
___________________________________________________________
City:
______________________________________________________________
State/Zip: __________________________________________________________
Country:___________________________________________________________
Phone:
____________________________________________________________
Witness:
___________________________________________________________