General Media Release Form
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:
City, State, Zip
Signature & Date
I am signing this form as an individual
I am signing this form as a representative of a group, and have full authority to grant release for this group
Name of group
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
Address of Parent/Guardian (if different)
Phone Number (if different)
City, State, Zip Code
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