Image & Likeness Release

This release authorizes the Requestor to capture and use the Subject's image, likeness, voice, and recordings for the specific channels and purposes described below. The Subject controls which channels are permitted via the checkboxes in Section 3.

Section 1 — Subject

Subject full name:

Date of birth:

Email:

Phone:

Section 2 — Requestor

Requestor name or organization:

Requestor address:

Project / event name:

Section 3 — Permitted Channels (Subject controls)

Check ONLY the channels the Requestor is allowed to use. Unchecked channels are NOT authorized.

Requestor's own website and blog

Social media (Instagram, Facebook, TikTok, YouTube, LinkedIn)

Printed marketing materials (brochures, posters, flyers)

Paid advertising (online and offline)

Internal use (training materials, staff communications)

Press releases and editorial coverage

Section 4 — Excluded Uses

List any specific uses, contexts, or modifications the Subject does NOT permit (e.g., political advertising, adult content, AI training):

Section 5 — Term & Compensation

Authorization start date:

Authorization end date (leave blank for indefinite):

Compensation paid (currency and amount, write "none" if no compensation):

The Subject may revoke this release on 30 days written notice. Revocation does not affect materials already produced and distributed, but the Requestor will stop using the Subject's image in new productions after the notice period.

Section 6 — Acknowledgments & Signatures

I have read and understood this release.

I confirm I am the Subject identified above, or am authorized to sign on the Subject's behalf.

I consent to electronic signatures having the same legal effect as handwritten signatures.

Subject — printed name:

Date:

If the Subject is under 18, a parent or legal guardian must also sign:

Parent / guardian — printed name:

Date:

Optional — upload identification or a sample image/clip for reference:

This template is provided for reference only. Image rights law varies by jurisdiction. Consult qualified counsel before relying on this document, especially for minors or commercial use.