If you are submitting a photo for "Celebrating Our Lives," please print this form, fill it out and mail it to Triad Equality Alliance, P.O. Box 19842 Greensboro, NC 27419.

Please include the filename of your photo:________________________________

MODEL RELEASE

In consideration for value received, the receipt of which is hereby acknowledged, I hereby acknowledge that I have been informed and understand that Triad Equality Alliance (hereinafter "TEA") and Equality NC are producing a media campaign, said campaign to be known as "Celebrating Our Lives", and that my likeness, image, appearance, and/or performance will be made a part of said media campaign.

I hereby give TEA and Equality NC, TEA, their successors, assigns, agents, officers, employees, and subsequent parties in interest, the absolute right and permission to copyright and/or to publish and/or to use photographic portraits of me, or in which I may be included in whole or in part, or composite, or distorted in character or form, or reproductions thereof in color or otherwise, made through any media, for art, advertising, trade, or any other lawful purpose whatsoever. This grant includes without limitation the right to edit, mix, or duplicate and to use or re-use the product in whole or part as TEA and Equality NC, their successors, assigns, agents, officers, employees and subsequent parties in interest, may elect in the abOUT face campaign, as hereinabove defined. TEA and Equality NC shall have complete ownership of the product in which I appear, and I acknowledge that I have no interest in the product or its copyright. Further, I hereby waive any right that I may have to approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied.

I hereby release, discharge, and agree to hold harmless TEA, Equality NC, and their successors, assigns, agents, officers, employees, and subsequent parties in interest, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in any composite form, whether intentional or otherwise, that may occur in the taking of any photographs or in any processing involved in the completion of the finished product. Further, I hereby release and indemnify TEA, Equality NC, and their successors, assigns, agents, officers, employees, and subsequent parties in interest from any and all claims known and unknown arising out of or in any way connected with the usage of my likeness as hereinabove or hereinbelow set forth. I grant TEA (and Equality NC at the discretion of TEA), and their successors, assigns, and subsequent parties in interest the right to broadcast, exhibit, market, and otherwise distribute the finished product, as hereinabove defined, to educate regarding gay, lesbian, bisexual, and transgender issues. I hereby acknowledge that I understand that photographic portraits of me may be used in connection with the media campaign identifying the subjects of said portraits as members of the gay, lesbian, bisexual, and transgender community.

I hereby represent that I am at least eighteen (18) years old as of the date of the signing of this document and that I am not incapacitated, incompetent, or otherwise unable to enter into this agreement. In the event that I am a minor, I understand that the signature of my parent or legal guardian will be a necessary part of my participation in the hereinabove identified media campaign.


Name (Print)
___________________________________________________________________


Name (Signature)
_________________________________________ ____Date______________


Name of minor:
__________________________________________________________________


Signature of parent/guardian____________________________________Date_______________