Media Release Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

MEDIA RELEASE FORM

I, {{full_name}}, residing at {{address}}, hereby grant {{company_name}} ('the Company'), its representatives, and employees, irrevocable permission to use my likeness, statements, or testimonials in its promotional materials, including but not limited to photographs, videos, audio recordings, and written content. This release applies to all forms of media, including print, electronic, and online publications, for the purpose of promoting the Company's activities and services.

I understand that my participation is voluntary and that I will not receive any financial compensation for the use of my image, statements, or testimonials. I waive any right to inspect or approve the finished product wherein my likeness appears.

I further release the Company from any and all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf have or may have by reason of this authorization.

Purpose of Use

The media captured may be used for, but not limited to, the following purposes:

Marketing and promotional materials (brochures, advertisements, websites)

Public relations activities

Internal communications

Social media postings

Educational materials

Acknowledgement of Rights

I acknowledge that I am at least eighteen (18) years of age and competent to contract in my own name.

I have read this Media Release Form and fully understand its contents. I am aware that this is a release of liability and a contract, and I sign it of my own free will.

Optional: Specific Usage Limitations (if applicable)

I grant permission for general use as described above.

OR

I grant permission for use with the following specific limitations (please specify): {{usage_limitations}}

Contact Information

Full Name: {{full_name}}

Address: {{address}}

Phone Number: {{phone_number}}

Email Address: {{email_address}}

Signature Block

___________________________________

Signature of Releasor (Individual)

Name (Printed): {{full_name}}

Date: {{date}}

___________________________________

Signature of Parent/Guardian (if Releasor is under 18)

Name (Printed): {{parent_guardian_name}}

Date: {{date}}