PHOTOGRAPHIC CONSENT AND RELEASE FORM *

I hereby authorize Video Shop Productions LLC. and those acting in pursuant to its authority to: (a) Record my likeness and voice on a video, audio, photographic, digital, electronic or any other medium. (b) Use my name in connection with these recordings. (c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, memory card, Internet/WWW) these recordings for any purpose that Video Shop Productions LLC., and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release Video Shop Productions LLC. and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of Video Shop Productions LLC. and may be used multiple video production products for the customers of Video Shop Productions LLC. I have read and fully understand the terms of this release.

By checking this box I provide my electronic consent to the details within this form.

Name *

First Name

Last Name

Phone *

(###)

###

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Parent/Guardian Name

(if under 18)

First Name

Last Name

Date *

MM

DD

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