In consideration of the sum of $1.00 and other good and valuable consideration, receipt of which is hereby acknowledged, I,                            being of legal age, hereby give                         (hereinafter the Videographer), and all licensees, successors, legal representatives and assigns of the Videographer, the absolute and irrevocable right and permission to use my name and to use, reproduce, edit, exhibit, project, display, copyright, publish and/or resell photographic pictures and/or moving pictures and/or videotaped images of me with or without my voice, or in which I may be included in whole or in part, and any of my possessions, including real and personal property, which photographic and/or moving pictures, videotaped images and/or possessions are photographed, taped, videotaped, and/or recorded on                 , 19    and thereafter, and to circulate the same in all forms and media (including, but not limited to: videotapes, audio tapes, compact discs, computer files, film, slides and photographs) for art, advertising, trade, competition of every description and/or any other lawful purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith. I acknowledge that I have no interest, ownership or copyright rights in any pictures, images or recordings or in any forms or media thereof produced by the Videographer.

I hereby waive any right that I may have to inspect and/or approve the finished product or products or the editorial, advertising or printed copy or soundtrack that may be used in connection therewith and any right that I may have to control the use to which said product, products, copy and/or soundtrack may be applied.

I hereby release, discharge and agree to save harmless the Videographer, his licensees, successors, legal representatives and assigns from any liability by virtue of any blurring, distortion, alteration, optical illusion or use in composite form whether intentional or otherwise, that may occur or be produced in the making, processing, duplication, projecting or displaying of said pictures, images, or recordings and from liability for violation of any personal or proprietary right that I may have in connection with said pictures, images, or recordings and with the use thereof.

Individual _______________________
Witness __________________________

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