Photo/Video Consent and General Release Form
I hereby authorize the American Cancer Society to use pictures of me (or my child/ward) taken in a
photograph, digital image, videotape, motion picture, and/or testimonial (written words). The
undersigned hereby releases the American Cancer Society, its agents or employees, as well as any
and all users and exhibitors of said pictures, from any and all claims, demands, accountings, and
causes for which the aforesaid videotape, testimonial, motion picture, digital image, or photograph
likeness may be used pursuant to this Consent and General Release. It is also my understanding that I
will receive no compensation for my likeness or testimonial.
Signature:
_______________________________________ Date: __________________
Printed Name:_______________________________________
Name of person(s) in photo, if different: _______________________________________
Address
_______________________________________
_______________________________________
Phone(s):
_______________________________________
Email:
_______________________________________
Witness
Signature:
_______________________________________ Date: __________________
Printed Name: _______________________________________