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Media Release Form


Media Release Form
Media Release Form
I grant permission to mindPOP to use my image (photographs and/or video) for use in mindPOP
publications including videos, email blasts, recruiting brochures, newsletters, and magazines and
to use my image in electronic versions of the same publications or on the mindPOP website or
other electronic forms of media.
I hereby waive any right to inspect or approve the finished photographs or electronic matter that
may be used in conjunction with them now or in the future, whether that use is known to me or
unknown, and I waive any right to royalties or other compensation arising from or related to the
use of the image.
Please check the paragraph below which is applicable to your present situation:
_____I am 20 years of age or older and I am competent to contract in my own name. I have read
this release before signing below, and I fully understand the contents, meaning and impact of this
release. I understand that I am free to address any specific questions regarding this release by
submitting those questions in writing prior to signing, and I agree that my failure to do so will be
interpreted as a free and knowledgeable acceptance of the terms of this release.
_____I am the parent or legal guardian of the below named child. I have read this release before
signing below, and I fully understand the contents, meaning and impact of this release. I
understand that I am free to address any specific questions regarding this release by submitting
those questions in writing prior to signing, and I agree that my failure to do so will be interpreted
as a free and knowledgeable acceptance of the terms of this release.
Date: ____________
Name (please print):_______________________________________________________
Address: ________________________________________________________________
Signature: _______________________________________________________________
Signature of parent or legal guardian (if under 20 years of age):____________________
Media Release Form