Media Release Consent Form

A release form that records who is granting permission to use their photo or video, who is receiving that permission, and how the media will be used, with signed attestations confirming legal age or guardian consent.

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In the Claude connectors directory

Page 1

Date

Name of Releasor

First Name

Last Name

Phone Number

Name of Person Photographed/Filmed

First Name

Last Name

Phone Number

The Media obtained shall be used for

Page 2

Name of Releasee

First Name

Last Name

Email of Releasee

Phone Number of Releasee

Age of Releasee

Address of Releasee

Street Address

City

State / Province

ZIP / Postal Code

Page 3

Section: Attestations

Attestation of Legal Age

I attest that I am 18 years of age or older

Attestation of Parent/Guardian

I attest that I am the legal parent/guardian of the minor and give my consent

Signature of Releasor or Releasor's Guardian

Sign here

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