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General Media Release Form
Production Title _______________________________________________________________
Production Date _____ /_____ /_________
I, the undersigned, hereby authorize ____________________ to photograph me, takemotion
pictures of me,take video footage of me, and/or make electronic soundrecordings of me (herein
referred to as photographic or electronic reproductions).
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 bedeemed appropriate
by ___________________________ (I understand that I may be identifiablefrom such
photographic or electronic reproduction).
I understand that there will be no financial or other remuneration for recording me, either for
initial or subsequent transmission or playback.
I waive any rights, claims, or interest I may have to control the use of my identity or likeness in
whatever media used.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY
Agreed and accepted by:
Print Name ____________________________________________________________________
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