Model Release Form


For Consideration herein acknowledged as received, and by signing
this release I hereby give the Photographer / Filmmaker and Assigns
(Aligned to top right-hand corner if larger than box.)
my permission to license the Content and to use the Content in any
Media for any purpose (except pornographic or defamatory) which may
For example, Polaroid, drivers license, print, photocopy, etc.
include, among others, advertising, promotion, marketing and packag-
ing for any product or service. I agree that the Content may be com-
I have consented to publication of my ethnicity(ies) as indicated below,
but understand that other ethnicities may be associated with me by the
Photographer / Filmmaker and / or Assigns for descriptive purposes.
I agree that I have no rights to the Content, and all rights to the Content
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
Name (print) ______________________________________________
following list that is nearest to the address of the Model (or Parent*) giv-
en opposite: New York, Alberta, England, Australia and New Zealand.
Date of Birth (DD/MM/YEAR) _________________________________
Gender: male
It is agreed that my personal information will not be made publicly avail-
able but may only be used directly in relation to the licensing of the
Content where necessary (e.g. to defend claims, protect rights or notify
Residence Address _________________________________________
purpose, including by being shared with sub-licensees / assignees of
the Photographer / Filmmaker and transferred to countries with differing
data protection and privacy laws where it may be stored, accessed and
City ________________________State/Province _________________
used. I represent and warrant that I am at least 18 years of age and
have the full legal capacity to execute this release.
Country ____________________ Zip/Postal Code ________________
Phone _____________________ Email ________________________
: “ASSIGNS” means a person or any company to whom
Signature _________________________________________________
Photographer/Filmmaker has assigned or licensed rights under this
release as well as the licensees of any such person or company. “CON-
Date signed
SIDERATION” means $1 or something else of value I have received
in exchange for the rights granted by me in this release. “CONTENT”
*If Model is a minor or lacks capacity in the jurisdiction of residence,
Parent warrants and represents that Parent is the legal guardian of
taken of me as part of the Shoot. “MEDIA” means all media including
Model, and has the full legal capacity to consent to the Shoot and to
known or to be invented. “MODEL” means me and includes my appear-
are signing in this capacity, please enter your details above and your
ance, likeness and voice. “PARENT” means the parent and/or legal
name below.
guardian of the Model. Parent and Model are referred to together as “I”
and “me” in this release, as the context dictates. “PHOTOGRAPHER
Parent Name:_____________________________________________
tographer, or any other person or entity photographing or recording me.
if applicable
in this form.
Witness (NOTE: All persons signing and witnessing must be of legal
age and capacity in the area in which this Release is signed. A person
Name (print) _____________________________________________
cannot witness their own release)
Signature _______________________________________________
Date signed
Name (print) ______________________________________________
Shoot Date ______________________________________________
Signature ________________________________________________
Shoot Country & Region/State ______________________________
Date ____________________________________________________
Shoot Description/Ref. _____________________________________


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