Permission To Use Picture

I hereby give Your-Company-Name the absolute right and permission to publish, copyright and use pictures of me in which I may be included in whole or in part, composite or retouched in character or form, in conjunction with (initial those applicable):

_______my own name
_______a fictitious name
_______no name to be used

If the person photographed is under 18, I certify that I am his or her parent or legal guardian and I give my consent without reservation to the foregoing on his or her behalf.

Date: _____________________________________
Name: ____________________________________
Address:___________________________________
Phone: ____________________________________
Signature:__________________________________