Date

MM

DD

YYYY

Model Name

First Name

Last Name

Parent Name

First Name

Last Name

Phone

(###)

###

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I hereby grant to Bellemore Imagery (“Photographer”), her legal representatives and assigns, those for whom Photographer is acting, and those acting with his/her authority and permission, the absolute right and permission to take, use, reuse, publish, and republish photographic portraits or pictures of the minor or in which the minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with the minor’s own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising, trade, or any other purpose whatsoever. I also consent to the use of any published matter in conjunction therewith. *

I agree

I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents thereof. This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns. *

I agree