his heirs, legal representatives and assigns, those for whom he is acting, and those acting with his authority and permission, throughout the world, in connection with the photographs he has taken of me, or in which I may be included with others:

a)

The unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformation in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.

I also permit the use of any printed material in connection therewith, including, without limitation, all promotional and advertising uses, and other trade purposes,.

I hereby relinquish any right that I may have to examine or approve any part whatsoever of the completed product or products that may be used in conjunction therewith or the use to which it may be applied.

I hereby release, discharge and agree to save harmless the photographer noted above, his heirs, legal representatives or assigns, and all persons or companies functioning under his permission or authority or to whom said photographs are submitted for sale or resale, or those for whom he is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or he produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

______ I represent that I am over the age of eighteen years and that I have read the foregoing and fully and

completely understand the contents hereof.

______ I represent that the model is a minor and that I am the parent or duly authorized representative of the

model and that I have read the foregoing and fully and completely understand the contents hereof.

By signing below, I state that I understand that falsification of this document would be against the law and I would be responsible for any fines, injunctions, or court orders, or legal proceedings surrounding falsification of this document.

ALL FIELDS ARE REQUIRED