Reiki Photography Model Release Form

In consideration for the value received, the receipt of which is acknowledged, I do hereby authorize John Cook (Photographer), his legal representatives, successors, and all persons or corporations acting with his permission, (including clients, purchasers, agencies and periodicals or other printed matter and their editors) to copyright and/or use, and/or publish photographic portraits or pictures of me, in conjunction with my name (or fictitious name) for sale to or reproduction in any medium the photographer or her designees see fit for purposes of advertising, display, audiovisual, exhibition, editorial use or any other lawful purpose.

I hereby waive any right that I may have to inspect and approve the finished product or copy that may be used in connection with an image that the Photographer has taken of me, or the use to which it may be applied.

I further release the Photographer, or others for whom he is acting, from any claims for remuneration associated with any form of damage, foreseen or unforeseen, associated with the proper commercial or artistic use of these images unless it can be shown that said reproduction was maliciously caused, produced and published for the sole purpose of subjecting me to conspicuous ridicule, scandal, reproach, scorn and indignity.

I acknowledge that the photography session was conducted in a completely proper and highly professional manner, and this release was willingly signed at its termination. I certify that I am not a minor, and am free and able to give such consent.

(Please Print)

MODEL'S NAME ______________________________________________________

TELEPHONE______________________ E- MAIL____________________________

ADDRESS______________________________________________________________

CITY__________________________STATE__________ZIP CODE______________.

DATE OF BIRTH_____________________

SS NUMBER (if monetary payment was given)____________________________

I DECLARE UNDER PENALTY OF PERJURY THAT ALL OF THE INFORMATION I HAVE GIVEN ABOVE IS TRUE AND CORRECT AND THAT I AM MORE THAN 18 YEARS OF AGE.

(Model's signature) (Date)

(Witness or photographer)

This form will be retained with the negatives, transparencies, CD’s and/or contact sheets. © Reiki Photography 2009