Adult Release Form

I, [PRINT NAME]______________________________________________________, do
hereby give my permission for the University of Western Sydney, to use this
photographic material or video footage (described below) in official University business,
including: University Web sites, University newsletters, newspapers and promotional
material. I hereby waive any claim for payment for use of the material or footage.

It is agreed that the use of this photographic material or video footage shall in no way be
used in any other forum other than for official University business.

I hereby waive any right that I may have to inspect or approve the finished product and
the advertising copy or other matter that may be used in connection with the material or
footage or the use to which it may be applied. I hereby release the University from any
infringement or violation of personal and or property rights of any sort whatsoever based
upon the use of the photographic material or video footage.

Taken/created on the _________ day of ___________________2010

_______________________________
Signature

Description of what I am wearing today: ……………………………………………………….

Ph: ………………………………………………………………………………………………….

Staff:  Student:  Other: 

Campus :…………………………………………………………………………………………...

Course :…………………………………………………………………………………………….

Shoot details and description:

……………………………………………………………………………………...

PLEASE ENSURE THIS FORM IS FAXED BACK TO 9678 7095

OFFICE OF MEDIA AND COMMUNICATION

Level 1, Bldg AF, Werrington North Campus
Phone: 02 9678 7082
Fax: 02 9678 7095