N o r t h e r n E s s e x C o m m u n i t y C o l l e g e
Model Release Form
DATE: _______________________________ LOCATION/EVENT: ___________________________________
I acknowledge and consent to the use of my photograph/image/video footage in any and all publications,
videos, and online communications created by Northern Essex Community College. I waive any rights to
compensation in any form. The college is not required to obtain my permission to reuse or republish this
photograph/image/video footage in the future. A parental/guardian signature is required for those under 18 years
of age.
SIGNATURE: __________________________________________________________________________
Participant or Parent/Guardian if under 18
NAME: _______________________________________________________________________________
ADDRESS: ___________________________________________________________________________
CITY, STATE, ZIP: _____________________________________________________________________
PHONE: ______________________________________________________________________________
EMAIL: _______________________________________________________________________________
Revised 03/31/14
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