Media Release eForm
Permission to Use Photograph
Event
Your answer
Location
Your answer
Full Name
Your answer
Name of Parent
Only if the media we are using has a person under the age of 18 years old. Type N/A if this form is for yourself.
Your answer
Phone Number
Your answer
Email Address
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
I grant The MJ Treatment, the right to take photographs of me. I authorize The MJ Treatment, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
Required
I agree that The MJ Treatment may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Required
I have agreed to submit this form by electronic means. By signing this application electronically, I given my consent and/or parental consent for my child and that I certify that all the information I have provided to be accurate. (Type your full name after typing "/s/". Example: /s/ Jane Doe )
Your answer
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