Photo/video release form

Above The Influence Network

Photo/ Video Release Form

First name

Last name

Address

Phone

Consent Confirmation

I agree that Above The Influence Network (ATI) and/or any agency acting on their behalf, shall have the right to photograph me, (still or moving) and/or to record my voice and/or performance by any present or future means. ATI and their successors and assignees shall own all results and proceeds of my services, including the copyright in same and as such owner shall have the right:

a. to include them in any advertising & publicity

b. to reproduce them by any present or future means

c. to exhibit and perform them on radio and television and in, or by any other present or future media, for profit or otherwise, and for commercial or non-commercial purposes.

I agree to the statement above.

I agree to make no claims against ATI and their successors and assignees for any payment by way of a fee for appearing in promotional material or advertisements.

I agree to the statement above.

Signatures

Signature

Date

Signature (ATI)

Date

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