General Media Release Form
Production Title  		_ 	_ Production Date     _ /_     / 	

1)   I, the undersigned, hereby authorize _ 	to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).

2)   I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by  	(I understand that I may be identifiable from such photographic or electronic reproduction)

Agreed and accepted by:

Print Name	 	_ 	_

Title

 	_ 	_

Address

 	_ 	_

City, State, Zip	 	_ 	_

Phone

 	_ 	_

Signature & Date	 	_ 	_ I am signing this form as an individual  DYes DNo
I am signing this form as a representative of a group, and have full authority to grant release for this group  DYes DNo

Name of group  	_ 	_ 	

PARENTAL CONSENT

I certify that I am the parent or guardian of the individual above,  	, a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this General Media Release.

 	_ 		 	_
Signature of Applicant’s Parent/Guardian	Date

 	_ 	

( 	_) 	

Address of Parent/Guardian (if different)	Phone Number (if different)

 	_ 	 City, State, Zip Code