Release Form

I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded on audio or video without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse settings within an unrestricted geographic area.

Photographic, audio, or video recordings may be used for the following purposes:

Television Advertising
Internet Advertising
Print Advertising
Radio Advertising

By signing this release I understand this permission signifies that photographic, video, or audio recordings of me may be electronically displayed via the Internet, Television, Radio, and various Print Mediums.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio, or video recordings collected voluntarily or as part of my employment assignment only.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against RS Fiber Cooperative or any person or organization affiliated with RS Fiber Cooperative utilizing this material.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

By re-entering my name below, I agree to be bound by the items outlined in this form.*

Date*

If this release is obtained from a presenter under the age of 18, then permission from that presenter’s parent or legal guardian is also required. By entering my name below, I hereby agree, on behalf of the presenter under the age of 18 indicated in the above documentation, to be bound by the stipulations in this form.

Date

By entering your email in the field below, you will receive a confirmation email and copy of this form.

Release Form

RS Fiber Photograph, Audio, and Video Release Form

(800) 628-1754

Residential

Business

Customers