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General Media Release Form 2

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General Media Release Form 2
General Media Release Form
Production Title _______________________________________________________________
Production Date _____ /_____ /_________
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).
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).
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.
Agreed and accepted by:
Print Name ____________________________________________________________________
Address ______________________________________________________________________
City, State, Zip _________________________________________________________________
Phone _______________________________________________________
Witness for the undersigned _______________________________________________________
Signature _______________________________________ Date _________________________
General Media Release Form 2