Image Release Form Template

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IMAGE RELEASE FORM TEMPLATE
By signing this release form, I authorize [name of company and or creative outlet granted rights], to use the following
personal information:
(1) My picture – including photographic, motion picture, and electronic (video) images.
(2) My voice – including sound and video recordings.
I hereby grant to [name of company and or creative outlet granted rights], its subsidiaries, licensees, successors and assigns,
the right to use, publish, and reproduce, for all purposes, my name, pictures of me in film or electronic (video) form, sound
and video recordings of my voice, and printed and electronic copy of the information described in sections (1) and (2) above
in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition,
distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences and in brochures
and other print media. This permission extends to all languages, media, formats and markets now known or hereafter devised.
This permission shall continue forever unless I revoke the permission in writing. Any finished work utilizing said content will
stay available.
I further grant [name of company and or creative outlet granted rights] all right, title, and interest that I may have in all
finished pictures, negatives, reproductions, and copies of the original print, and further grant [name of company and or
creative outlet granted rights] the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for
marketing, communications, or advertising purposes, as it deems fit.
I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment for [name
of company and or creative outlet granted rights] use of any of the material described above for any of the purposes
authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or
advertising recordings and copy or printed matter or computer generated scanned image and other electronic media that may
be used in conjunction therewith or to approve the eventual use that it might be applied.
I acknowledge that I have read the foregoing and I fully understand the contents.
IN WITNESS WHEREOF, I have executed this release on this ____ day of __________, [YEAR].
Print Name:
Telephone Number:

Address:
Signature:

City/State/Zip:
(If release is provided on behalf of a minor:)
I hereby certify that I am the parent or guardian of ______________, who is under the age of eighteen years, to whom this
release applies and that I have the legal authority to execute this release. I approve the foregoing and agree that we both shall
be bound thereby.
Parent/Guardian:
Telephone Number:
Address:
Signature:
City/State/Zip:
Witness:
Telephone Number:
Address:
Signature:
City/State/Zip:
Telephone Number:
Signature:

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