Personal Release Form printable pdf download

PERSONAL RELEASE FORM

Name:__________________________________________________________________________

Address: ________________________________________________________________________

City: ________________________________________ State: ___________ Zip:______________

Telephone: ___________________________________Cell:______________________________

E-mail Address: __________________________________________________________________

Starting Date: ___________________________________________________________________

Contemplated Ending Date: ________________________________________________________

Payment (if applicable): ___________________________________________________________

Tentative Title of Film:____________________________________________________________

Name of Filmmaker:______________________________________________________________

Address: ________________________________________________________________________

City: _______________________________________ State: ___________ Zip:_______________

Telephone: _____________________________________________________________________

E-mail Address: _________________________________________________________________

Producer:_______________________________________________________________________

For good and valuable consideration received, the sufficiency of which is hereby acknowledged, I,

________________________________________________________________________

(print full name ), hereby irrevocably grant to

_____________________________________________________________ (insert name of filmmaker),

its subsidiaries, affiliates, nominees, licensees, their successors and assigns, and those acting with its

authority (hereinafter collectively referred to as “Filmmaker”), with respect to the photographs, film,

video, recordings or tape taken of me by or on behalf of Filmmaker (the “Materials”), the unrestricted

absolute, perpetual, worldwide right to:

(a) Reproduce, copy, modify, create derivatives in whole or in part, or otherwise use the Materials or

any part thereof in combination with or as a composite of other matter, including, but not limited to, text,

data, images, photographs, illustrations, animation and graphics, video or audio segments of any nature,

in any media or embodiment, now known or hereafter to become known, including, but not limited to, all

formats of computer readable electronic magnetic, digital laser or optical-based media (the “Works”) for

any purpose whatsoever, and

(b) Use and permit to be used my name, whether in original or modified form, in connection with the

Works as Filmmaker may choose, and

hereafter to become known.

I hereby waive all rights and release and discharge Filmmaker from, and shall neither sue nor bring any

St. Louis Volunteer Lawyers and Accountants for the Arts

Personal Release Form