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Policyholders

Photo/Video Consent Form

We would be grateful if you would fill in this form to give us permission to take photos and use these in our printed and online publicity.

* denotes required field

Your Name
Company
Signature
Date

Permission and Rights Granted
I herein acknowledged by signing this release I hereby give the Photographer and Assigns my permission to license the Images and to use the Images in any Media for any purpose (except pornographic, defamatory, libellous or otherwise unlawful) which may include, among others, advertising, promotion, marketing and packaging for any product or service. I agree that the Images may be combined with other images, text and graphics, and cropped, altered or modified. I acknowledge and agree that I have consented to publication of my ethnicity(ies) as indicated below, but understand that other ethnicities may be associated with Images of me by the Photographer and/or Assigns for descriptive purposes. I agree that I have no rights to the Images, and all rights to the Images belong to the Photographer and the Assigns. I acknowledge and agree that I have no further right to additional Consideration or accounting, and that I will make no further claim for any reason to Photographer and/or Assigns. I acknowledge that this release can be revoked at any time by contacting .

Definitions
"Assigns" means a person or any company to whom the Photographer has assigned or licensed rights under this release as well as the licensees of any such person or company.

"Images" means all photographs taken of the Model as part of the Shoot.

"Media" means all media including digital, electronic, print, television, film and other media now known or to be invented.

"Model" means me and includes my appearance, likeness and form.

"Shoot" means the photographic or film session described in this form.

Please note, if the subject is under 18 parental permission must be granted and emailed to

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