Media Release Form

Personal Details

Name *

First

Last

Layout

Email *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth

Media Release

Title

Title/description of work

Author

Author/creator of the work

Source

Source of the work, such as a link to a web page

License

The Media Can Be Used in the Following:

Check all that apply

Consent *

I hereby consent to the use of my image, audio, and video

Release of Liability *

I hereby agree to release all liability from this organization

Terms and Conditions *

I hereby agree to the following terms and conditions

1. YOUR AGREEMENT

By agreeing to this media release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Today's Date *

Signature *