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2012 Video Contest Model Release Form All video contest entries with an identifiable person or persons must be accompanied by the release form provided below. If the subject or subjects are under 18, a parent/guardian needs to sign the model release form. Please submit a separate form for each person in the video. Videos of people without release forms will not be entered into the contest. _____________________________________________________________________ In exchange for good and valuable consideration, I consent in perpetuity to the use of video of me and/or my child by Ohio State Park Lodges and Xanterra (including any agency, client, periodical or other publication). This consent applies in all forms known now or in the future, in all media and in all manners, including, but not limited to, advertising, art, editorial, electronic and exhibition.
Videographer’s Information: Name: Telephone Number: E-mail: Model’s Information: Name: Telephone Number: E-mail:
Check here if this model is a child under 18. Model’s Signature: ____________________________________________________________ __________________________________ Parent / Guardian Printed Name (if under 18)
______________________________ Parent / Guardian Signature
_______________________________ Relationship to Model
______________________________ Signature Date
You may either scan and e-mail this signed form to
[email protected], or mail the form to: Ohio State Park Lodges Photo Contest, Attention: Video Conest, 3593 Medina Road, Medina, OH 44256, or fax to: (866) 497-6596.
