Sample Photo/video Release Form


Photo/Video Release   F orm
I, _____________________________________________________________(please print),
grant permission to Purdue University and its agents and employees the irrevocable and
unrestricted right to reproduce the photographs and/or video images taken of me, or
members of my family, for the purpose of publication, promotion, illustration, advertising,
or trade, in any manner or in any medium. I hereby release Purdue University and its legal
representatives for all claims and liability relating to said images or video. Furthermore, I
grant permission to use my statements that were given during an interview or guest lecture,
with or without my name, for the purpose of advertising and publicity without restriction. I
waive my right to any compensation.
I acknowledge that I am
[ ] over the age of 18
[ ] the legal guardian of the following
If legal guardian of model(s), please list name(s) here:
Name(s): ________________________________________________________________
Signature: _________________________________________Date: _________________
Address: ________________________________________________________________
M&M / Revised January 2015


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