Fillable Model Release Form2 (State University of New York at Farmingdale)

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Model Release Form2 (State University of New York at Farmingdale)

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BROWSE STATE UNIVERSITY OF NEW YORK AT FARMINGDALE FORMS

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AUTHORIZATION AND RELEASE
( Please Print Clearly and Legibly )
The State University of New York at Farmingdale State College (the “College”) produces and releases a
variety of instructional, information and promotional materials including printed and electronic matter,
photographs, videotapes, discs and computer files.
I, ___________________________________, hereby grant to the College and its agents or employees
exclusive permission to reproduce, in whole or in part, for its educational, informational or promotional
purposes, photographs, videotapes and other media materials which may include my picture or image,
without compensation to me, in any and all media, whether now known or hereafter existing, and for other
use by the University. I waive any right to inspect or approve the finished media materials.
I voluntarily and irrevocably give my consent and agree to this release and waiver.
Signature: _______________________________________________________
Date: _______________________________________________________
Print Name: _______________________________________________________
DOB: _______________________________________________________
Address: _______________________________________________________
City, State, Zip: _______________________________________________________
Phone: _______________________________________________________
Email: _______________________________________________________
Department / Major: _______________________________________________________
Accomplishment to be publicized: _______________________________________________________
Please list two accomplishments of which you are particularly proud: ___________________________
__________________________________________________________________________________
FOR MINORS
Parent / Guardian: _______________________________________________________
Signature: _______________________________________________________
Please return to the Office of Institutional Advancement, Horton Hall room 115,
or send to kathy.coley@farmingdale.edu, or fax to 631-420-2693.
2350 Broadhollow Road (Route 110) • Farmingdale, New York 11735-1021 • 631-420-2000 • www.farmingdale.edu
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Model Release Form2 (State University of New York at Farmingdale)

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Completed 25 July 2020

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