Photo Release Form - The Permanente Journal printable pdf download

Photo Release Form - The Permanente Journal

VIDEO/PHOTO RELEASE FORM

500 NE Multnomah Street

Suite 100

Portland, OR 97232

I authorize The Permanente Press to publish my likeness in a photograph/video

in print and on The Permanente Journal/The Permanente Press Web site

without compensation. I understand that this includes using the image without

restriction as to frequency and duration of usage, without compensation to me,

and in any manner and with whatever written copy it chooses. I understand that

The Permanente Press and Kaiser Permanente, and their employees or agents,

bear no responsibility for the contents in any news media coverage or any

pirated material in which I am featured as a result of this/these

photograph(s)/video(s).

I warrant that I am at least 18 years of age and that I am competent in my own

name insofar as this consent is concerned. I further attest that I have read this

consent form and fully understand its contents.

Description of video or photograph:

________________________________________________________

Signature _______________________________________________

Name (please print)

Date ___________________________________________________

Photo Release Form - The Permanente Journal