In consideration of_______________Dollars I (Print Model's Name)________________________ hereby grant to ________________________ (Photographer's Name) and his/her legal representatives and assigns, the irrevocable and unrestricted right to use and publish photographs of me, or in which I may be included, for editorial, trade, advertising and any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release Photographer and his/her legal representatives and assigns from all claims and liability relating to said photographs.

Date ____________

Signature __________________________ Phone ____________

Address _________________________________________________

City ________________________ State ____ Zip __________

If Minor, Signature of Parent/Guardian___________________

Witness _________________________________________________