Photo Release Form for Adult Subject

Chemical Education Xchange Model Release Form

Date:   _________________________

 

To:     _________________________

 

           _________________________

 

           _________________________

  

I am preparing material to be published at Chemical Education Xchange (www.ChemEdX.org), an online community of chemistry educators.

I would like your permission to include a copy of the attached photograph(s) in which you appear. To indicate your permission, please sign and date the statement below and return this form to me.

I appreciate your prompt response.

__________________________________________________(signature)

I hereby grant Chemical Education Xchange royalty-free permission, including non-exclusive world rights in all languages, to reproduce in all formats including but not limited to print, electronic and web-based to reproduce and include my likeness as shown in the attached photocopy(ies) of photograph(s) for Chemical Education Xchange.

Agree to and accepted:

Signature:  _______________________________    

Date:_________________ 

Check one: 

_____  I am the person in the photograph(s).

 _____  I am the authorized agent of the person in the photograph(s).

Submit this completed form to  _________________________

                                                  _________________________

                                                  _________________________