Sample photo and video release form - If you wish to capture audio or video footage, this is a great way to make sure the interview subject knows you will not be using their likeness in ways they do not authorize.

1. CONSENT TO PHOTOGRAPH
Photo / Video Release Authorization
Dated:
I, __________________________________________________________________________ (full name, printed)
of__________________________________________________________________________ (full address)
(Hereinafter “Signer”), for good and valuable consideration, hereby give permission to <company name> (Hereinafter
“COMPANY.”), to make audio video, and still recordings of myself (or my minor child, as the case may be, such
person being referred to herein as “Subject”), for the purposes ofinternal marketing research. I understand that
Subject’s first name and portrait, picture or video clips in all forms of media (“Likeness”) are for internal use only and
will not be used in any form whatsoever that is accessible to anyone otherthan officers and employees of COMPANY,
its consultants,investors orpotential investors,and its clients or potential clients, all of whom shall be under agreement
not to disclose such use.
My heirs, executors, and administrators shall be bound by this instrument.
_______________________________
Signature
______________________________ ______________________________
Signature of parent or guardian if Subject is a minor Relationship to Subject
_______________________________
Witnessed by: