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General Media Release Form 1


General Media Release Form 1
General Media Release Form
Production Title ____________________________________
Production Date ___ /___ /___
1) I, the undersigned, hereby authorize ____________________ to photograph me, take
motion pictures of me, take video footage of me, and/or make electronic sound
recordings of me (herein referred to as photographic or electronic reproductions).
2) I authorize the use of any such photographic or electronic reproductions of me for any
purpose, including, but not limited to educational and other public media as may be
deemed appropriate by ____________________ (I understand that I may be identifiable
from such photographic or electronic reproduction)
Agreed and accepted by:
Print Name ______________________________________
Title ______________________________________
Address ______________________________________
City, State, Zip ______________________________________
Phone ______________________________________
Signature & Date ______________________________________
I am signing this form as an individual Yes No
I am signing this form as a representative of a group, and have full authority to grant release for
this group Yes No
Name of group ______________________________________
PARENTAL CONSENT
I certify that I am the parent or guardian of the individual above, ___________________, a minor
under the age of eighteen years. I hereby agree to assume legal responsibility for his/her
authorizations referred to in this General Media Release.
____________________________________ ________________
Signature of Applicant’s Parent/Guardian Date
____________________________________ (_____)___________________
Address of Parent/Guardian (if different) Phone Number (if different)
____________________________________
City, State, Zip Code
General Media Release Form 1