I, the undersigned, do hereby consent and agree that [insert organization name here], its employees, or agents have the right to take photographs, videotape, or digital recordings of me beginning on [insert event date] and ending on [insert date here] , and to use these in any and all media, now or hereafter known, and exclusively for the purpose of their website, literature, promotional and fundraising activities.

I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to [insert organization name here], its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies.

I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

I also understand that [insert organization name here] is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Name: ____________________________________________

Date: ___________________

Address: __________________________________________________________________

Phone: ___________________________________________________________________

Signature: __________________________________________

Guardian’s signature if person is under age of 18:________________________________

Can we contact you at this number to follow up between events? Yes: _____ No:_____