Model’s Name: ____________________________________________________
Model’s Address: __________________________________________________
_________________________________________________________________
_________________________________________________________________
Model’s Phone: ____________________________________________________
Model’s E-mail: ____________________________________________________
Attach visual reference here, aligned to top right-hand corner if larger than box.
For example,
Polaroid, drivers license, print, photocopy, etc.

MODEL’S PERMISSION AND RIGHTS GRANTED:
For good and valuable Consideration herein acknowledged as received, and by signing this release I hereby give the Photographer/Filmmaker and Assigns my permission to license the Images and to use the Images in any Media for any purpose (except pornographic or defamatory) which may include, among others, advertising, promotion, marketing and packaging for any product or service. I agree that the Images may be combined with other images, text and graphics, and cropped, altered or modified. I acknowledge and agree that I have consented to publication of my ethnicity(ies) as indicated below, but understand that other ethnicities may be associated with Images of me by the Photographer/Filmmaker and/or Assigns for descriptive purposes.
I agree that I have no rights to the Images, and all rights to the Images belong to the Photographer/Filmmaker and Assigns. I acknowledge and agree that I have no further right to additional Consideration or accounting, and that I will make no further claim for any reason to Photographer/Filmmaker and/or Assigns. I acknowledge and agree that this release is binding upon my heirs and assigns. I agree that this release is irrevocable, worldwide and perpetual, and will be governed by the laws of the state of New York, excluding the law of conflicts.
I represent and warrant that I am at least 18 years of age and have the full legal capacity to execute this release.
Additional information to be completed by Model: (Optional)
Ethnicity information is requested for descriptive purposes only, and serves as a means of providing more accuracy in assigning search words.
___Asian – circle each that applies to you:
(Chinese, Indian, Japanese, Korean)
___Asian, Other ___Caucasian, White
___Hispanic, Latin ___Middle Eastern
___Native American ___Pacific Islander
___Black ___Mixed Race
___African American
Other:

 

****************************************************************************************************************************************************************************************
To be completed By Model:
Model’s Signature:______________________________________Date:____________
Model’s
Printed Name:___________________________________________________
Model’s Date of Birth: ____________________
DEFINITIONS:
“MODEL” means me and includes my appearance, likeness and form.
“MEDIA” means all media including digital, electronic, print, television, film and other
media now known or to be invented.
“PHOTOGRAPHER/FILMMAKER” means photographer, illustrator, filmmaker or
cinematographer, or any other person or entity photographing or recording me.
“ASSIGNS” means a person or any company to whom Photographer/Filmmaker has
assigned or licensed rights under this release as well as the licensees of any such
person or company.
“IMAGES” means all photographs, film or recording taken of me as part of the Shoot.
“CONSIDERATION” means something of value I have received in exchange for the
rights granted by me in this release.
“SHOOT” means the photographic or film session described in this form.

 

 

********************************************************************************************************************************************************************************
__________________________________The following to be completed by Photographer/Filmmaker_________________________________

Photographer’s/Filmmaker’s Name: _______Robert Farmer________________________ Shoot Date: _______________________________
Release Reference-Stills Only (e.g. mr1.jpg)

Photographer/Filmmaker’s Signature: __________________________________________________

Shoot Description [and Shoot Reference if applicable]: ____________________________________

________________________________________________________________________________
Adult Std USA 0406