I _________________________, the undersigned, hereby grant permission to __________________________
(Producer) to photograph me and to record my voice, performances, poses, acts, plays, and appearances, and to
use my picture, photograph, silhouette and other reproductions of my physical likeness and sound as part of the
tentatively entitled picture listed above and the unlimited distribution, advertising, promotion, exhibition, and
exploitation of the picture by any method or device now known or hereafter devised in which the same may be
used, and/or incorporated, exhibited, or exploited.
I agree that I will not assert or maintain against you, your successors, assigns and licenses, any claim, action,
suit or demand of any kind or nature whatsoever, including but not limited to, those grounded upon invasion of
privacy, rights of publicity or other civil rights, or for any other reason in connection with your authorized use
of my physical likeness and sound in the picture as herein provided.
I affirm that neither I, nor anyone acting for me, gave or agreed to give anything of value to any of your
employees or any representative of any television network, motion picture studio or production entity for
arranging my appearance on the picture.
I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound,
I have signed this release.
PRINT NAME: __________________________________ DATED: _______________________________________
If a minor, Guardian’s Signature: ___________________________________________________________
ADDRESS: ________________________________________ PHONE: ____________________________________