Consent Of Media Release
Date
Month Day Year
Date
Name of Releasor
First Name Last Name
Phone Number
Name
First Name Last Name
Phone Number
The Media obtained shall be used for
marketing, flyer, and brochures social media/websites Video Use Other

Agreed and Accepted by
Name of Releasee
First Name Last Name
Email of Releasee
example@example.com
Phone Number of Releasee
Age of Releasee
Address of Releasee
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

CONFIRM
I, (hereinafter referred to as "Releasor"), grants permission to ABC Company (hereinafter referred to as "Releasee"), to use my media (photograph image and/or video footage and/or audio recordings).
I likewise understand that I may be identifiable from the reproduction of the media by the Releasee indicated herein this agreement.
I hereby waive my rights to inspect or approve the media for production that may be used by the Releasee for purposes stated herein, from hereon forward.
I likewise waive any right to royalties or any compensation arising from or related to the use of the image.
Attestation of Legal Age
I certify that I am of legal age and competent to contract in my own name. I have read this release before signing below and I fully understand the contents, terms, and the effect of this release.
Attestation of Parent/Guardian
I am the parent or legal guardian of the named minor in this agreement. I have read this release before signing below, and I fully understand the contents, terms, and the effect of this release.
Signature of Releasor or Releasor's Guardian
Clear
Should be Empty:

Consent Of Media Release

Agreed and Accepted by