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MODEL'S RELEASE FOR VIDEOTAPED MATERIALS and PRODUCTIONS and or Pictures Submitted
Model 's Full Name____________________________________________________________ Address____________________________________________________________ City__________________________________State ___________ Zip ___________
____________________ Telephone (home)
____________________ Telephone (work)
I hereby give____________________________ (Videographers Name) his / her successors and assigns, the absolute right and permission to copyright, and or use my pictures, videotaped material in whole or in part, composite or distorted in character or form, in conjunction with my own or a fictitious name, with reproduction thereof in color or otherwise, made through any media at any studio or elsewhere, for an, advertising, trade or any other lawful purpose whatsoever. I hereby release, discharge and agree to save_______________________________. Videographers Name his / her successors, assigns, and agents from all liability in connection with the copyright or distribution of my pictures, videotaped material and or model information pertaining to me. I hereby waive any right that I may have to inspect and or approve the finished video production, audio track, and printed matter that may be used in connection therewith, or the use to which it may be applied. I hereby represent that I am over the age of 18 years and I have read this authorization and release prior to its execution. I have not been coerced to execute this release.
Signature___________________________________________________
IMPORTANT: To show that model's signature is genuine it must be notarized.
STATE OF_________________________________________________
County of_____________________________
On this _______day of________________201______Before me personally appeared _____________________________ known to me to be the person executing the foregoing release he / she executed the same for the purposes therein stated.

NOTARY PUBLIC




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