Model Release Form
In consideration of my engagement as a model, I
______________________ here after referred to as model, upon the terms herewith
stated, hereby give to photographer Robert M. Osiecki, his heirs, legal
representatives and assigns, those for whom Robert M. Osiecki is acting, and
those acting with his authority and permission:
I. The unrestricted right and permission to copyright and use,
re-use, publish, and republish photographic portraits or pictures of me or in
which I may be included intact or in part, composite or distorted in character
or form, without restriction as to changes or transformations in conjunction
with the model’s own name or fictitious name, or reproduction hereof in color or
otherwise, made through any and all media now or hereafter known for
illustration, art, promotion, advertising, trade, or any other purpose
whatsoever.
II. I also permit the use of any printed material in connection
therewith.
III. I hereby relinquish any right that I may have to examine
or approve the completed product, photographic image or advertising copy or
printed matter that may be used in conjunction therewith or the use to which
said images may be applied.
IV. I hereby release, discharge and agree to save harmless
photographer Robert M. Osiecki, his heirs, legal representatives or assigns, and
all persons functioning under his permission or authority, or those for whom he
is functioning from any liability by virtue of any blurring, distortion,
alliteration, optical illusion, or use in composite form whether intentional or
otherwise, that may occur or be produced in the taking of said picture or in any
subsequent processing thereof, as well as any publication thereof, including
without limitation any claims for libel or invasion of privacy.
V. I hereby affirm that I am over the age of majority and have
the right to contract in my own name. I have read the above authorization,
release and agreement, prior to its execution. I fully understand the contents
thereof. This agreement shall be binding upon me and my heirs, legal
representatives and assigns.
Signed: ______________________________________ Dated: ______________________________
