Back On My Feet Photo Release Form
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1Back on My Feet Photo Release Form
Participant information
For good and valuable Consideration herein acknowledged as
Name (print)
received, and by signing this release I hereby give the
Address
Photographer/Filmmaker and Assigns my permission to
license the Images and to use the Images in any Media for any
City _______________________________ State/Province
purpose (except pornographic or defamatory) which may
County __________________________ Zip/Postal Code
include, among others, advertising, promotion, marketing and
Phone ____________________ Email
packaging for any product or service. I agree that the Images
Signature
may be combined with other images, text and graphics, and
Date
cropped, altered or modified. I acknowledge and agree that I
have consented to publication of my ethnicity(ies) as
Parent(s) or Guardian(s) (if person is a minor or lacks capacity
indicated below, but understand that other ethnicities may be
in the jurisdiction of residence.) Parent warrants and
associated with Images of me by the Photographer/Filmmaker
represents that Parent is the legal guardian of Participant, and
and/or Assigns for descriptive purposes.
has the full legal capacity to consent to and execute this
release OF ALL RIGHTS IN PARTICIPANT’S IMAGES.
I agree that I have no rights to the Images, and all rights to the
Images belong to the Photographer/Filmmaker and Assigns. I
Name (print)
acknowledge and agree that I have no further right to
Address
additional Consideration or accounting, and that I will make
City _______________________________ State/Province
no further claim for any reason to Photographer/Filmmaker
County __________________________ Zip/Postal Code
and/or Assigns. I acknowledge and agree that this release is
binding upon my heirs and assigns. I agree that this release is
Phone ____________________ Email
irrevocable, worldwide and perpetual, and will be governed
Signature
by the laws of the United States of America.
Date
I represent and warrant that I am at least 18 years of age and
Additional information to be completed by Participant:
have the full legal capacity to execute this release.
(Optional)
Ethnicity information is requested for descriptive purposes
Definitions:
only, and serves as a means of providing more accuracy in
“MEDIA” means all media including digital, electronic, print,
assigning search words.
television, film and other media now known or to be invented.
“PHOTOGRAPHER/FILMMAKER” means Back on My Feet
___Asian
___Caucasian,
___Hispanic, Latin
(which includes any photographer, illustrator, filmmaker or
White
cinematographer, or any other person or entity
___Middle
___Native
___Pacific Islander
photographing or recording at the direction of Back on My
Eastern
American
Feet).
___Black
___Mixed Race
___African
“ASSIGNS” means a person or any company to whom
American
Photographer/Filmmaker has assigned or licensed rights
Other:
under this release as well as the licensees of any such person
or company.
“IMAGES” means all photographs, film or recording taken of
Attach Visual reference of Participant here: (Optional)
me in connection with my participation in the Back on My
For example, Polaroid, drivers license, print, photocopy, etc.
Feet program including but not limited to my appearance,
likeness, voice, name, and form.
“CONSIDERATION” means something of value I have received
in exchange for the rights granted by me in this release.
“PARENT” means the parent and/or legal guardian of the
Witness (NOTE: All persons signing and witnessing must be of
Participant. Parent and Participant are referred to together as
legal age and capacity in the area in which this Release is
“we” and “us” in this release.
signed. A person cannot witness their own release)
Name (print)
Signature
Date
____
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