Media Release Form
Name of Adult Student
I hereby authorize and consent to the use of my visual image by priyachellani.com and yourfriendlyphotographer.com, for appropriate purposes, including but not limited to: still photography, video tape, electronic and print publications, and websites. I give this consent with no claim for payment.
Signature *
Date *
MM
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DD
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YYYY
Phone Number (in case we need to contact you) *
For a child UNDER 18 years of age, I, the Parent or Guardian, hereby authorize and consent to the use of my child's visual image by priyachellani.com and yourfriendlyphotographer.com, for appropriate purposes, including but not limited to: still photography, video tape, electronic and print publications, and websites. I give this consent with no claim for payment.
Name of Parent/Guardian of Minor/Adult with Disability *
Signature *
Date *
MM
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DD
/
YYYY
Phone Number (in case we need to contact you) *
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