Photo Model Release Form

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SCHOOL OF NURSING
Photo Model Release Form
I, _____________________________________________________________(please print
student full name),
_____ grant permission to Purdue University School of Nursing to reproduce photographs 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.
_____ deny permission to Purdue University School of Nursing to reproduce photographs 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 understand this denial does not apply to
the School of Nursing Graduation composite picture.
Acceptance or denial of permission is completely voluntary and will in no way affect a students
academic standing within the School of Nursing.
I acknowledge that I am
_____ over the age of 18
_____ the legal guardian of above student
____________________________
Printed guardian name
Signature______________________________________________________________________
Date
______________________________________________________________________
Address ______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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