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(This is a sample of the form we will email to you)

MEDIA RELEASE FORM

I, _______________________________

(printed name)

With a mailing address of ________________________

City of ________________________,

State of ________________________ Zip Code ______________

An email address of _______________________________

And phone number of ________and or modification________________

(the “Releasor”) grants permission and ownership to and consent to KGEL Radio (the “Releasee”) for the use of and or modification of the following photograph(s) and or video(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, reproduction, advertising, and web content:

_____________________________________________________________________

_____________________________________________________________________

Describe Photo(s) and or Video(s)

Please check the following to show your confirmation

Ownership of media

c I, the releasor, do certify that I am the owner of the above listed media.


Payment

c I understand that there shall be no payment for this release.

Royalties

c I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Revocation

c I understand that with my authorization below the use of and ownership of the media may never be revoked.

Confirmation and Agreement

c I am 20 years of age or older

or

c I am the parent or legal guardian of the child (20 years or younger) signing below

and

I have read this complete release before signing below, and I fully understand the contents, meaning and impact of this release and agree to the aforementioned terms and conditions. My signature below confirms a free and knowledgeable acceptance of the terms of this release.

Releasor’s Signature ______________________ Date ______________

Print Name _______________________________

If the releasor is under 20 years of age a parent or legal guardian must sign below:

Parent or Legal Guardian Signature _______________________________

Print Name _______________________________