Photo Release Form
hereby grant Dodge County Farm Bureau permission to use my likeness in a
photograph or video in any and all of its publications, including website entries, without
payment or any other consideration.
understand and agree that these materials will become the property of the Dodge
County Farm Bureau and will not be returned.
I hereby irrevocably authorize the Dodge County Farm Bureau to edit, alter, copy,
exhibit, publish or distribute this photo/video for purposes of publicizing the Dodge
County Farm Bureau’s programs or for any other lawful purpose. In addition, I waive the
right to inspect or approve the finished product, including written or electronic copy,
wherein my likeness appears. Additionally, I waive any right to royalties or other
compensation arising or related to the use of the photograph.
hereby hold harmless and release and forever discharge the Dodge County Farm
Bureau from all claims, demands, and causes of action which I, my heirs,
representatives, executors, administrators, or any other persons acting on my behalf or
on behalf of my estate have or may have by reason of this authorization.
am 21 years of age and am competent to contract in my own name. I have read this
release before signing below and I fully understand the contents, meaning, and impact
of this release.
(Printed Name) (Date)
f the person signing is under age 21, there must be consent by a parent or guardian, as
I hereby certify that I am the parent or guardian of _________________________, named
above, and do hereby give my consent without reservation to the foregoing on behalf
of this person.
(Parent/Guardian’s Signature) (Date)
(Parent/Guardian’s Printed Name) (Date)