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Model Release Form
MODEL’S EMAIL ADDRESS:
MODEL’S MAILING ADDRESS:
POSING FOR PHOTOGRAPHS TAKEN ON (date):
December 10 - 11, 2016
121 Bigger Road Cumberland, VA 23040 (Commonly known as Level Five)
I hereby assign full copyright of these photographs and videos to the above-mentioned photographer
together with the right of reproduction either wholly or in part.
I grant to the Photographer the permission to use the above-mentioned photographs and videos either
separately or together, either wholly or in part, the perpetual, irrevocable and unrestricted right to use
and publish video and/or photographs of me, or where I may be included for editorial trade, product
advertising and such other business purpose in any manner and medium.
The Photographer may have unrestricted use of these materials for whatever purpose, including
advertising, with any retouching or alteration without restriction.
I agree that the above mentioned photographs and videos and any reproductions shall be deemed to
represent an imaginary person, and further agree that the Photographer or any person authorized by or
acting on his or her behalf may use the above mentioned photographs or any reproductions of them for
any advertising purposes or for the purpose of illustrating any wording, and agree that no such wording
shall be consid-ered to be attributed to me personally unless my name is used.
Provided my name is not mentioned in connection with any other statement or wording which may be attributed to me personally, I undertake not to Prosecute or to institute proceedings, claims or demands
against either the Photographer or his or her agents in respect of any usage of the above mentioned photographs. I hereby release the photographer named above from all claims and liability relating to images,
video or photographs taken of me.
I have read this model release form carefully and fully understand its meanings and implications.
Important: If the Model is under 18 year of age, a parent or legal guardian must also sign
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