I do hereby grant permission to [Sponsor Name], its agents, and others working under its authority, full and free use of video/photographs containing my image/likeness.  I understand these images may be used for promotional news, research and/or educational purposes.

I hereby release, discharge, and hold harmless [Sponsor Name] and its agents from any and all claims, demands, or causes of action that I may hereafter have by reason of anything contained in the photographs or video.

I do further certify that I am either of legal age, or possess full legal capacity to execute the foregoing authorization and release.  If the picture is of a minor, [Insert legal age of authority for your individual state, ex.- 17 years of age or younger], the signature of a parent or legal guardian is required.

Name (Please Print) _______________________________________


Signature _______________________________________________


Guardian's Name (Please Print) ______________________________


Guardian's Signature ______________________________________


Phone Number ___________________________________________


Date ___________________________________________________