Alta Lodge Photography/Video Release

For valuable consideration received, including for the opportunity to have my photographs published, I give Alta Lodge Company, and any person who is authorized to act on its behalf, permission to take, use and publish photographs and or video of me (or my child if named below), or in which I or they may be included for use in editorial, news, web, email, print, trade and advertising media.

Event: *
Date: *
Name: *
Signature: *
Name 2:
Signature 2:
Address:
City, State, Zip:
Telephone(s):
E-mail: *
Photographer:
Photographer Email:
Photographer Phone:
Notes/Conditions:
If under 18 years of age:
Name(s) of Minor(s):
Minor's Date(s) of Birth:
Signature of Parent or Legal Guardian:
Name of Witness:
Signature of Witness:
 
  

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