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Wisconsin Model Release Form 4

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This form is provided by the University of Wisconsin-Parkside to grant the permission of the use and publication of the releasor's photographic pictures or portraits.

Wisconsin Model Release Form 4
Wisconsin Model Release Form 4
900 Wood Road, PO Box 2000
Kenosha, Wisconsin 53141-2000
Marketing and Publications Office
Telephone: (262) 595-2403
Fax: (262) 595-2440
MODEL RELEASE
For and in consideration of my engagement as a model by the University of Wisconsin-Parkside, hereafter
referred to as the photographer, on terms hereinafter stated, I hereby give the photographer, his or her
legal representatives and assigns, those for whom for photographer is acting, and those acting with his or
her permission, or his or her employees, the right and permission to copyright and /or use, reuse and/or
publish, and republish photographic pictures or portraits of me, or in which I may be distorted in charac-
ter, or form, in conjunction with my own or a fictitious name, on reproductions thereof in color or black
and white made through any media by the photographer at his or her studio or elsewhere, for any pur-
pose whatsoever, including the use of any printed matter in conjunction therewith.
I hereby waive any right to inspect or approve the finished photograph or advertising copy or printed
matter that may be used in conjunction therewith or to the eventual use that it might be applied.
I hereby release, discharge and agree to save harmless the photographer, his or her representatives,
assigns, employees or any person or presents, corporation or corporations, for whom he or she might be
acting, including any firm publishing and/or distributing the finished product, in whole or in part, from
and against any liability as a result of any distortion, blurring or alteration, optical illusion or use in com-
posite form, either intentionally or otherwise, that may occur or be produced in the taking, processing or
reproduction of the finished product, its publication or distribution of the same, even should the same
subject me to ridicule, scandal, reproach, scorn or indignity.
I hereby warrant that I am under/over 18 (eighteen) years of age, and competent to contract in my own
name in so far as the above is concerned.
I have read the foregoing release, authorization and agreement before affixing my signature below, and
warrant that I fully understand the contents thereof.
Dated:
Name (L.S.): Print name:
Address
Witness (L.S.) Print name:
Address
Wisconsin Model Release Form 4