PHOTO RELEASE FORM
I, ______________________ with a mailing address of
________________________ City of ______________________, State of
______________________ (the “Releasor”) grant permission and consent
to ______________________ (the “Releasee”) for the use of the following
photograph(s) as identified below for presentation under any legal
condition, including but not limited to: publicity, copyright purposes,
illustration, advertising, and web content:
____________________________________________________________
Describe Photo(s)
Payment (check one)
☐ - I understand that there shall be no payment for this release.
☐ - I understand that there shall be a payment for this release in the
amount of $_____________.
Royalties (check one)
☐ - I understand that there shall be royalties for the photographs used in
the amount of _______________________________________________.
☐ - I understand that no royalty, fee, or other compensation shall become
payable to me by reason of such use.
Revocation (check one)
☐ - I understand that with my authorization below the photograph(s) may
never be revoked.
☐ - I understand that I may revoke this authorization at any time by
notifying the Releasee in writing. The revocation will not affect any actions
taken before the receipt of this written notification. Images will be stored in
a secure location and only authorized staff will have access to them. They

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will be kept as long as they are relevant and after that time destroyed or
archived.
We, the Releasor and Releasee, have understand and agree to the
aforementioned terms and conditions.

Releasor’s Signature ______________________ Date ______________
Print Name ______________________ Date ______________
Releasee’s Signature ______________________ Date ______________
Print Name ______________________ Date ______________

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