Consent and Release Form

           

With no expectation of compensation or other remuneration, now or in the future, I hereby give my consent to AGELESS WOMAN MAGAZINE and AGELESS WOMAN EXPO, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).  This consent includes, but is not limited to:

 

 (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

 

 (b) Permission to use my name (although use of name will not in all cases be required); and

 

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

           

This consent is given in perpetuity, and does not require prior approval by me. 

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I also give them permission to interview others about me and to use that information gathered as they see fit.

 

It has been fully explained and I understand that even if my story is used in an attempt to gain help for me in the form of volunteer assistance, funds, donations of items, etc., there is no guarantee that there will be a response to the public solicitation on my behalf, and I understand I may not receive any assistance at all if none is forthcoming in response to my story.

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I understand that Ageless Woman Magazine, at their discretion, may choose not to use my story for any reason, and I may or may not be privy to those reasons.

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Printed Name:                                                                                                                        

 

Signature:                                                                                                                   

 

Address:                                                                                                                     

 

              

Date:                                      

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If children will also be featured, please also list their names and have the parent/guardian sign below.

 

The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

 

Signature of Parent

or Legal Guardian:

 

Printed Name:                                                   

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The following is required if the consent form has to be read to the parent/legal guardian:

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I certify that I have read this consent form in full to the parent/legal guardian whose signature appears above.

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Date:

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Witness Signature:

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Signature of Ageless Woman Representative Acknowledging Receipt of Consent Form and Release:

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Date: