EmailMe Form - General Photo/Video Release

General Photo/Video Release

In consideration of $0 Dollars ($0) receipt of which is acknowledged, I, do hereby give Wartburg College, his or her assigns, licensees, and legal representatives the irrevocable right to use my name (or any fictional name), picture, portrait, or photograph in all forms and media and in all manners, including composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith.

Event Name *
Student Name *
First Last
Please confirm. *
I am 18 years of age or older.
I am under the age of 18.
If younger than 18, you must provide the name of parent/guardian below who will sign this waiver.
High School *
Parent/Guardian Name *
First Last
Email *
Phone *
### - ### - ####
Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Today's Date *
MM / DD / YYYY
Please select to confirm *
I have read this release and am fully familiar with its contents.
Signature *
Clear
Parent/Guardian: I am the parent or guardian of the minor named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.