Photography by Lloydlee Heite
204 N. Main Street, Bridgeville De 19933
(302) 337 8545
www.lloydlee.com
Name:_____________________________________________________________
Current Address:____________________________________________________
____________________________________________________
Home Phone:________________________ Age:_______
Birth Date:________________ Social Security #:___________________
E-mail Address:_____________________________
Agency/Agent:____________________________________________________
Agent Phone Number:________________________
Emergency Contact Name:_______________________________________
Emergency Contact Phone #:________________________
For good and valuable consideration, the sufficiency of which is hereby acknowledged, I do hereby
give Lloydlee Heite the absolute right to display, publish or sell in his own name, or the name of his
company, employer, client, and to use in any manner, photographic portraits or pictures of me, or in
which I may be included in whole or in part, or composite or distorted in character or form, in
conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made
through any media including digital and video, for art, advertising, trade, news, or any other lawful
purpose whatsoever and in conjunction with any copy, captions, photograph and headings
whatsoever.
I do hereby irrevocably waive any right that I may now have or hereafter acquire, by operation of
law or otherwise, to inspect and/or approve the finished product, the printed material or the
advertising and/or editorial copy, captions, and headings that may be used in conjunction therewith,
or the use to which it may be applied.
I do hereby release, discharge, and agree to save Lloydlee Heite his assigns, heirs or successors,
whether individual, corporate or otherwise, and those acting under his authority or permission, from
any liability by virtue of any use whatsoever and including any blurring, distortion, alteration, optical
illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in
tending toward the completion of the finished product.
I do hereby warrant that I am of full legal age and have every right to contract in my own name in
the above regard and further that I have read the above authorization and release prior to its
execution and that I am familiar with the contents thereof. If I am not of legal age, I have so indicated
below and the signature of my parent or guardian upon this release, said parent or guardian agrees
to indemnify and hold harmless the photographer or publisher from any and all liability whatsoever in
connection with relying upon said release agreement.
This agreement has been fully read and understood by the parent or guardian, if said model is under
18 years of age, prior to signing.
Model Signature:______________________________________________
Witness Signature:______________________________________________
Parent/Guardian Signature:____________________________________
Signature Date:______________________