Fillable Printable General Media Release Form

General Media Release Form

Production Title ____________________________________

Production Date ___ /___ /___

1) I, the undersigned, hereby authorize ____________________ to photograph me, take

motion pictures of me, take video footage of me, and/or make electronic sound

recordings of me (herein referred to as photographic or electronic reproductions).

2) I authorize the use of any such photographic or electronic reproductions of me for any

purpose, including, but not limited to educational and other public media as may be

deemed appropriate by ____________________ (I understand that I may be identifiable

from such photographic or electronic reproduction)

Agreed and accepted by:

Print Name ______________________________________

Title ______________________________________

Address ______________________________________

City, State, Zip ______________________________________

Phone ______________________________________

Signature & Date ______________________________________

I am signing this form as an individual Yes No

I am signing this form as a representative of a group, and have full authority to grant release for

this group Yes No

Name of group ______________________________________

PARENTAL CONSENT

I certify that I am the parent or guardian of the individual above, ___________________, a minor

under the age of eighteen years. I hereby agree to assume legal responsibility for his/her

authorizations referred to in this General Media Release.

____________________________________ ________________

Signature of Applicant’s Parent/Guardian Date

____________________________________ (_____)___________________

Address of Parent/Guardian (if different) Phone Number (if different)

____________________________________

City, State, Zip Code