Model Release Form

Talent's Name *

First

Last

Date of Photo / Video Shoot *

Location of Photo / Video Shoot *

Talent's Date of Birth *

Talent's Phone Number

Talent's Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Guardian's Consent

• I am the parent and/or the legal guardian of the above-mentioned person. I hereby approve the forgoing consent of the above-mentioned company to use, subject to the terms mentioned below.

Guardian's Name *

First

Last

Address Talent's Phone

Guardian Date of Birth *

Guardian Phone

Guardian's Address If Different

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Consent Authorization *

• I hereby authorize Greenfields Outdoor Fitness, Inc. to use my photographs and/or video images reproduction and/or likeness in any medium for the purpose of instruction, education, advertising, display, print, exhibition, video, commercial, website and/or editorial use. I authorize the unlimited use and reproduction of any and all photographs and other materials. I understand all such photographs and related materials are and will forever remain the sole property of Greenfields Outdoor Fitness, Inc.

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