Non Disclosed 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. I understand under the terms for modeling under a Non
Disclosed Modeling situation that as the model, I retain the right to
copyright the images from photographer Robert M. Osiecki and to use, re-use,
publish, and republish photographic portraits or pictures of the model or in
which I may be included intact or in part, composite or distorted in character
or form, without any 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, personal web site, or any
other purpose whatsoever.
II. I understand that Photographer Robert M. Osiecki is in
agreement not to publish, republish, submit, or copyright the photographic
portraits or pictures of the model or in which the model may be included intact
or in part, composite or distorted in character or form, with restrictions 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, personal web site, or any other purpose
whatsoever.
III. 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.
IV. 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: ______________________________
Photographer: _________________________________ Dated: ______________________________
