Release Form
I understand the photograph(s) or video or audio recording(s) taken of me by agents, employees or
representatives of The Regents of the University of California (hereinafter called “the University”) shall
be used in connection with the University’s dissemination of information by its public service and
academic programs to the general public.
I hereby irrevocably authorize the University to copy, exhibit, publish or distribute any and all such
images and audio of me or wherein I appear, including composite or artistic forms and media, for
purposes of publicizing University programs or for any other lawful purpose. In addition, I waive any
right to inspect or approve the finished product, including written copy, wherein my likeness appears.
I hereby hold harmless and release and forever discharge the University from all claims, demands and
causes of action which I, my heirs, representatives, executors, administrators or any other persons
acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Project Title:
(You may pre-enter the title on this line before printing.)
(You may pre-enter date here.)
(Signature)
(Date)
(Printed Name)
(Street Address)
(City, State, Zip Code)
(If the person signing is under age 21, there should be consent by a parent or guardian, as
follows:)
I hereby certify that I am the parent or guardian of ______________________________ ,
the minor named above, and do hereby give my consent without reservations to the
foregoing on behalf of this person.
(Parent/Guardian’s Signature)
(Date)
(Parent/Guardian’s Printed Name)