Photo Release For Adults - Girl Scouts Central Maryland
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1Girl Scouts Central Maryland
4806 Seton Drive
Baltimore, MD 21215-3247
T 410.358.9711, 800.492.2521
F 410.358.9918
PHOTO RELEASE FOR ADULTS
SERVICE UNIT#____________
TROOP #_____________________
DATE(S):________________________________________________________________________________________________________
ASSIGNMENT: ___________________________________________________________________________________________________
COUNCIL (IF APPROPRIATE): ______________________________________________________________________________________
PHOTOGRAPHER/PRODUCER: ____________________________________________________________________________________
DATE(s): ________________________________________________________________________________________________________
LOCATION: _____________________________________________________________________________________________________
ACTIVITY: _______________________________________________________________________________________________________
For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent
and agree to the following:
1.
I acknowledge that I am eighteen (18) years of age or older.
I hereby grant to Girl Scouts of Central Maryland
(GSCM)
and others working for GSCM or on its behalf, and each of its respective licensees, successors and assigns
(each a “Releasee”), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish,
exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture,
likeness and voice (including any video footage of the same) (collectively, “Media”), or to refrain from so doing, anywhere
in the world, by any persons or entities deemed appropriate by Girl Scouts of Central Maryland, for any purpose
(except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial
purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the
internet, in print campaigns, in-store and via television.
I agree that I have no interest or ownership in any of the Media.
2.
I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based
upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or
use in any composite form of my name, picture, likeness and voice.
I agree that nothing in this Release will create any
obligation on Girl Scouts of Central Maryland to make any use of the Media or the rights granted in this Release.
I hereby release and hold harmless Releasees from any claim for injury, compensation or negligence resulting or arising
from any activities authorized by this Release and any use of the Media by Girl Scouts of Central Maryland.
HOME ADDRESS:______________________________________ CITY________________________ STATE_____ ZIP__________
DAYTIME PHONE: (_____)_______________________
ADDITIONAL PHONE (optional): (_____)_______________________
DATE:______________________________________________________________________________________________________
NAME (please print):_________________________________________________________________________________________
SIGNATURE:________________________________________________________________________________________________
(*will not be used for any other purposes or distributed to third parties)
EMAIL ADDRESS*:____________________________________@_______________________________________________
Any revisions to the text of this Release must first be approved in writing by Girl Scouts of Central Maryland prior to
the activity in order for the changes to be effective.
PLEASE RETURN COMPLETED AND SIGNED RELEASE TO TROOP LEADER
03-303
3/14
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