Permission to Use Pictures 

In consideration for value received, receipt whereof is acknowledged, I hereby give

Photographer’s Name:___________________________________________

the absolute right and permission to publish, copyright and use pictures of me in which

I may be included in whole or in part, composite or retouched in character or form, in

conjunction with (initial those applicable):

My Name:______________________________________________________

My Fictitious Name:______________________________________________

No Name to be Used:_____________________________________________

If the person photographed is under 18, I certify that I am his or her parent or legal guardian and I give my consent without reservation to the foregoing on his or her behalf.

Date:__________________________________________________________

Name:_________________________________________________________

Address:_______________________________________________________

Phone:_________________________________________________________

Signature:______________________________________________________