CEGUR'S CHIMERA GALLERY OF THE ARTS

MODEL RELEASE

DATE__________ORGANIZATION_______________________________

PHOTOGRAPHER_____________________________________________

ADDRESS_____________________________________________________

CITY______________________STATE_____________ZIP_____________

For valuable consideration, $___________, I hereby irrevocably consent to and authorize the use and reproduction by you, or anyone authorized by you, of any and all slides or photographs which you have this day taken of me, negative or positive for any purpose whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute your property, solely and completely.

I am over 18 years of age. YES________ NO________

MODEL NAME________________________________________________
Signature

MODEL NAME________________________________________________
Please Print

ADDRESS_____________________________________________________

PHONE_______________________________________________________

WITNESSED BY_______________________________________________
Signature of Witness

If the person signing is under 18, consent should be given by parent or guardian, as follows:

I hereby certify that I am the parent or guardian of:

______________________________________________________
Please Print

The model named above, and for value received I do give my consent without reservations to the foregoing on behalf of him or her or them.

DATED________________________________________________
Signature of Parent or Guardian

WITNESSED BY________________________________________
Signature of Witness