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Headshot Release and Permission Form

For valuable consideration, including being provided with a finished composite headshot, receipt of which is acknowledged, I, __________________________________________________________________ do hereby give Scott Grossberg, his assigns, licensees, successors in interest, legal representatives, and heirs the irrevocable right to use my name (or any fictional name), picture, portrait, or photograph in all forms and in all media and in all manners, without any restriction as to changes or alterations (including but not limited to composite or distorted representations or derivative works made in any medium) for advertising, trade, promotion, exhibition, or any other lawful purposes. I agree that Scott Grossberg owns the copyright in these photographs and I hereby waive any claims I may have based on any usage of the photographs or works derived therefrom. I am of full age* and competent to sign this release. I agree that this release shall be binding on me, my legal representatives, heirs, and assigns. I have read this release and am fully familiar with its contents.

Date:______________________________

Signature______________________________________________________________________________

Printed Name___________________________________________________________________________

Street Address__________________________________________________________________________

City_________________________________________________State_________________Zip__________

Phone (__________) ________________-______________________

*Consent (if applicable)

I am the parent or guardian of the minor named above and have the legal authority to execute the above release. I approve the foregoing.

Signature______________________________________________________________________________

Printed Name__________________________________________________________________________

 

Rev. 8/12/00

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  Copyright 2000-2005 by Scott J. Grossberg. All Rights Reserved.