Cody Unser First Step Foundation Photo Consent Form printable pdf download

Cody Unser First Step Foundation

Address: P.O. Box 56696

Albuquerque, New Mexico 87187

Tel: (505) 999-9550

Email:

Photo Consent Form

This form should be completed in INK

Name of Client/Participant: ___________________________________________________

(Please Print)

 I am over 18 yrs of age

Date: ___________________

I, the undersigned, hereby give my consent to The Cody Unser First Step Foundation, its

agents and employees, or other third parties who are authorized by The Cody Unser First

Step Foundation, for the performance of the photographic procedures or actions initialed

below.

(The undersigned should if possible initial for each activity approved; if undersigned is

unable to initial, then a witness should initial.)

Initial _______ Still-photographs or video of client/participant.

Initial _______ Print photography, television filming or other electronic images/recordings of

client/participant.

Initial _______

Other (describe below):

_______________________________________________________________________

This authorization is subject to the following limitations (write “none” if applicable):

_______________________________________________________________________

I understand that by signing this form The Cody Unser First Step Foundation retains

ownership of any photos, images or recordings obtained under this authorization. I also

understand that a complete explanation of how The Cody Unser First Step Foundation may

use any of the photos, images or recordings obtained under this authorization has been

provided verbally to me. I understand that by signing this Photographic Consent Form I

have authorized Cody Unser First Step Foundation to use my photo, image or recording.

I hereby waive any right to compensation for the use of any photos, images or recordings

obtained under this authorization, and I hereby release The Cody Unser First Step

Foundation, its agents, officers, and employees from liability resulting from or attributable to

any of the diving activities authorized above.

_______________________________________________________

Signature of Client/participant or legal representative

date

_______________________________________________________

Signature of witness

date

Cody Unser First Step Foundation Photo Consent Form