Fillable Printable Standard Media Release Form

Standard Media Release Form

Media Release Form

I grant permission to mindPOP to use my image (photographs and/or video) for use in mindPOP

publications including videos, email blasts, recruiting brochures, newsletters, and magazines and

to use my image in electronic versions of the same publications or on the mindPOP website or

other electronic forms of media.

I hereby waive any right to inspect or approve the finished photographs or electronic matter that

may be used in conjunction with them now or in the future, whether that use is known to me or

unknown, and I waive any right to royalties or other compensation arising from or related to the

use of the image.

Please check the paragraph below which is applicable to your present situation:

_____I am 20 years of age or older and I am competent to contract in my own name. I have read

this release before signing below, and I fully understand the contents, meaning and impact of this

release. I understand that I am free to address any specific questions regarding this release by

submitting those questions in writing prior to signing, and I agree that my failure to do so will be

interpreted as a free and knowledgeable acceptance of the terms of this release.

_____I am the parent or legal guardian of the below named child. I have read this release before

signing below, and I fully understand the contents, meaning and impact of this release. I

understand that I am free to address any specific questions regarding this release by submitting

those questions in writing prior to signing, and I agree that my failure to do so will be interpreted

as a free and knowledgeable acceptance of the terms of this release.

Date: ____________

Name (please print):_______________________________________________________

Address: ________________________________________________________________

Signature: _______________________________________________________________

Signature of parent or legal guardian (if under 20 years of age):____________________