Date of Birth *

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In consideration of my engagement as a model, and for other good and valuable consideration herein acknowledged as received, I hereby grant the following rights and permissions to GEORGI SILCKERODT OF SILCKERODT PHOTOGRAPHY (“Photographer") & THE CLIENT (whom we are shooting for), their heirs, legal representatives, and assigns, those for whom Photographer and /or Client is acting, and those acting with their authority and permission. They have the irrevocable, perpetual and unrestricted right and permission to take, use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in colour or otherwise, made through any medium at his/her studios or elsewhere, and in any and all media now or hereafter known, specifically including but not limited to print media and distribution over the internet for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I specifically consent to the digital compositing or editing of the portraits or pictures, including without restriction any changes or alterations as to colour, size, shape, perspective, context, foreground or background. I also consent to the use of any published matter in conjunction with such photographs. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection with them or the use to which they may be applied. I hereby release, discharge, and agree to hold harmless GEORGI SILCKERODT OF SILCKERODT PHOTOGRAPHY, her CLIENT or their heirs, legal representatives, and assigns, and all persons acting under his/her permission or authority or those for whom he/ she is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of such photographs or in any subsequent processing of them, as well as any publication of them, including without limitation any claims for libel or violation of any right of publicity or privacy. *

I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents of this document. This document shall be binding upon me and my heirs, legal representatives, and assigns.

Full Legal Name {Signature} *

First Name

Last Name

Today's Date *

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