I, (legal name) , being known within the
Society for Creative Anachronism as (name) , do hereby grant
permission to the SCA for the photograph of me taken by
to be used as follows (check all that apply, complete blanks as necessary):
OPTION #1 — RELEASE FOR ALL PHOTOGRAPHS
The SCA may publish any photograph taken of me in any SCA publication, including print, web and electronic.
I reserve the right to ask that any specific picture on the web or in electronic media to be removed.
PLEASE STOP: If you checked Option #1, do not check any of the Options below.
PM NEW 8/10
SCA MODEL RELEASE FORM
**If I am executing this Release as a Parent or Guardian, I consent to the use of my child’s image or photograph as set
out above, and I agree that if despite the Release, my child makes a claim against the SCA, I will hold harmless and
indemnify the SCA for any damages it may incur as a result of said claim.
I affirm and agree:
1. that this agreement shall be binding upon me and my heirs, legal representatives and assigns.
2. that I am over the age of majority and at least eighteen years of age and legally able to sign this release on
my own behalf. If I am not, the name and signature of my legal guardian appear below as authorization
for this use.
3. to indemnify and hold harmless the SCA in the event any claim is brought against the SCA by any person
claiming that this Release is not valid and enforceable or that I did not have lawful authority to grant the
above permission and rights to the SCA.
I have read the above Release prior to its execution and fully understand the contents and consequences thereof.
OTHER OPTIONS — GRANTS OF USE
The SCA may (check all that apply):
publish my photo once in an issue of ;
publish my photo no more than times in the above publication;
publish my photo with the article entitled ;
publish my photo in any re-print of the above publication including electronic form;
publish my photo on a SCA web site for ;
publish my photo with any article or as a stand-alone picture in any SCA
publication
, including print, web
and electronic.
SIGNATURE
DATE E-MAIL ADDRESS
MAILING ADDRESS
**LEGAL GUARDIAN NAME (Please Print)
LEGAL GUARDIAN SIGNATURE DATE
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