Release Form
For and in
consideration of my engagement as a producer/director, photographer, actor/actress,
designer, model, and/or Company/ Agency representative by__"THE VILLAGE IDIOT"_
hereafter referred to as the Author, on terms hereinafter stated, I hereby give
the Author and Publisher, their legal representatives and assigns, those for
whom the author and publisher are acting, and those acting with their
permission, or their employees, the right and permission to publish, copyright
and/or use, reuse and/or broadcast and republish pictures and features of, and
by me and/company/Agency, or in which I may be distorted in character, or form,
in conjunction with my own or a fictitious name, on reproductions thereof in
color, or black and white received from me by the Author for the purpose of
featuring and/or promoting me (the talent/company/agency) in the said book, and
any purpose whatsoever that has to do with the book and promoting the book,
including the use of any printed matter in conjunction herewith.
I hereby confirm
1) That I have seen
or inspected the finished feature, story and/or work, or advertising copy or
printed matter that may be used in conjunction therewith or the eventual use
that it might be applied.
2) That the author
has received no monies from me/the company/agency to feature me and/or the
company/agency in this book.
I hereby
release, discharge and agree so save harmless the author, publisher, his
representatives, assigns, employees or any person or persons, corporation or
corporations, acting under his permission or authority, or any person, persons,
corporation or corporations, for whom he might be acting, including any firm
publishing and/or distributing the finished product, in whole or in part, from
and against any liability as a result of any distortion, blurring, or
alteration, optical illusion, or use in any composite form, either
intentionally or otherwise, that may occur or be produced in the taking,
processing or reproduction of the finished product, its publication, distribution,
or broadcast of the same.
I declare that I
have the copy right to the pictures I have supplied and that the information I
have supplied about myself and/or company/agency is true.
I hereby certify
that I am (over/ below) twenty-one years of age, and competent to contract in
my own name in so far as the above is concerned.
I have read the
foregoing release, authorization and agreement, before affixing my signature
below, and warrant that I fully understand the contents thereof.
Dated…………………………………………………..
Name…………………………………………………….
(Legal Signature)
Address………………………………………………….
Witness……………………………………………………….
(Legal
Signature)
Address………………………………………………………
I hereby certify
that I am the parent and/or guardian of ____________________________, an infant
under the age of twenty one
Years, and in
consideration of and the purpose of the terms above hereby acknowledged, I
hereby consent that the feature/ story/ images which have been, or are about to
published by the author and/or publisher, may be used by him for the purposes
set forth in original release herein above, signed by the infant model, with
the same for and effect as if executed by me.
__________________________________________________
Parent or
Guardian (Legal Signature)
__________________________________________________
Address
