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Name of Individual Photographed
*
First
Last
Age
*
Date of Birth
*
Email of Individual
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Platforms Where Photos Can Be Shared
*
Facebook
Instagram
Twitter
Website
Print/Other
Do You Wish to be Tagged?
*
Yes
Depends on the Image
No
Can We Use Your Name?
*
Complete Name
First Name
Nickname
No name be used
Fake Name
What Portions of the Image(s) Can We Use?
*
Complete Image
Don't show my face.
Don't show my genitals
Other (please elaborate)
Additional Information
Conditions
*
I agree to the following terms
I hereby grant The 1001 Words, its directors, officers, employees, agents, and designees (collectively “The 1001 Words”) non-revocable permission to capture my image and likeness in videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that The 1001 Words will own such Images and further grant the The 1001 Words permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to The 1001 Words business as detailed above, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the The 1001 Words prior to its use. I forever release and hold the The 1001 Words harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity.
I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assignees and personal representatives.
Date of Agreement
*
Submit