JIDORI MOTION SELFIE CHALLENGE IMAGE RELEASE FORM

By signing this release I hereby consent and authorize the Jidori Motion Selfie Challenge or its
successor and assigns, to use, publish, and release my likeness, photos, videos and audio in any
and all media including without limitation cable and broadcast television and the Internet and for
exhibition, distribution, promotion, sales, advertising, educational venues and platforms,
publicity, festivals and markets, press releases, brochures, and other print media related to the
project. This permission extends to all languages, media, formats, and markets now known or
hereafter devised.
I hereby waive the right to receive any payment for signing this release and waive the right to
receive any payment for use of my use of any of the material described above for any other
purposes authorized by this release. I also waived any right to inspect or approve finished
photographs, video, audio, multimedia, or advertising and promotion related to the challenge.
I further consent to such use in its present form and to any changes, alterations, or additions
thereto. I hereby release the Challenge or its assigns from all liability in connection with all such
uses.
I acknowledge that I have read the foregoing and that I fully understand the contents.
Dated this day of _______________ 2015 .
Signed: ________________________
(Please print name) _____________________
City/State ____________________________
Witness: _________________________
Signed: ________________________
(Please print name) _____________________
If the motion selfie is of a minor, please have the parent or parental guardian sign below.
I hereby satisfy certify that I am the parent or guardian of _____________________, who is
under the age of 18 years, to whom this release applies and that I have the legal authority to
execute this release. I approve the foregoing and agree that we both shall be bound thereby.
Signed: ________________________
(Please print name) _____________________
City/State _______________________________
Witness

Signed: ________________________
(Please print name) _____________________