Adult Education Center Multi-Media Form

I,
____________________________________________________________(please print), grant permission to the Adult Education Center and its agents and employees the unrestricted right to reproduce the photographs and/or video images taken of me for the purpose of publication, promotion, illustration, advertising in any manner or in any medium. I hereby release the Adult Education Center and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.
I acknowledge that I am*
- over the age of 18
- the legal guardian of the following
If legal guardian of model(s), please list name(s) here:
Name
Signature*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

If legal guardian of model(s), please list name(s) here: