Heavensfield

For valuable consideration, I hereby confer on _____________________________________ (photographer’s name goes here) the absolute and irrevocable right and permission with respect to the photographs that he/she has taken of my minor child in which he/she may be included with others:

a) To copyright the same in _____________________________________ (photographer’s name goes here) name or any other name that he/she may select;

b) To use, re-use, publish and re-publish the same in whole or in part, separately or in conjunction with other photographs, in any medium now or hereafter known, and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion, advertising and trade, and;

c) To use my name or my child’s name in connection therewith if he/she so decides.

I hereby release and discharge _____________________________________ (photographer’s name goes here) from all and any claims and demands ensuing from or in connection with the use of the photographs, including any and all claims for libel and invasion of privacy.

This authorization and release shall inure to the benefit of the legal representatives, licensees and assigns of photographer _______________________________________ (photographer’s name goes here) as well as the person(s) for whom he/she took the photographs.

I have read the foregoing and fully understand the contents hereof. I represent that I am the [parent/guardian] of the above named model. For value received, I hereby consent to the foregoing on his/her behalf.

Dated: _______________________________________

Minor's Name:__________________________________

Parent or Guardian:_______________________________

Address:______________________________________

City:__________________________________________

State/Zip:______________________________________

Phone:________________________________________

Witness:_______________________________________