Consent Form
This [picture, video recording] will be used by a [institution] for [purpose].
I, [name of participant] do hereby consent to the use by [name of author] of my image, video,
voice, or all three, in the item described above.
In addition, I waive any right to inspect or approve the finished item.
I agree that all such pictures, video or audio recordings and any reproduction thereof shall
remain the property of the author who may use it as they see fit.
I understand that this consent is perpetual, that I may not revoke it, and that it is binding.
I understand that this may appear publicly.
Name:
Signature:
Date of Birth:
____________________________________________________________________________
It is understood that this material will be used in a legitimate manner and is not intended to
cause any harm or undue embarrassment to the parties involved.
Name of author:
Signature of author:
Date: