Media Release
[YOUR BUSINESS NAME HERE]

Please complete a separate release form for each person appearing in materials. Release may also be completed by a singular entity or organization responsible for multiple individuals, images and locations captured in the media.  Please provide all the information requested below.

Name: (print)__________________________________________________________________	
Address: ____________________________________________________________________

Phone:__________________________________	

Project:______________________________________________________________________
										
Please check all that apply:

This material may be used in the form of

 __X__ Photographs    _X___ Video    __X__ Audio    

to be used for the purpose of    marketing / promotion / instructional materials     by [YOUR BUSINESS] for an indefinite period of time, unless specified below.

* IF PERSON APPEARING IN THE MATERIAL IS UNDER I8 YEARS OF AGE, PARENT OR LEGAL GUARDIAN MUST SIGN THIS FORM BELOW.

I (we) give my (our) permission to [YOUR BUSINESS] to use my name (or my child’s name), city and state, and/or photograph, voice, videorecording, or any likeness for publicity, marketing and instructional materials including the use of statements made by or attributed to me (or my child) relating to [YOUR BUSINESS] for this or similar media and grant to [YOUR BUSINESS] any and all rights to said use without further compensation. It is my (our) understanding that my signature below releases [YOUR BUSINESS] from any financial or legal responsibility for the use of this media/promotional material(s).

Signed: __________________________________________________________	

Date: ______________________________	

* Printed Name of Parent or Guardian Granting Permission: ____________________________ (signing if under 18)

Relationship: _______________________________