Visual/Audio Release Form
Email completed form to
I hereby grant permission to Lesley University to use my image, representations of my audio and/or visual works and my verbal and written
statements for promotional purposes in University publications, advertising, video, web, social media, or other formats. The images may be used
now or in the future. I understand that I waive any right to inspect or approve the finished images/footage or any printed or electronic materials and
that Lesley University does not owe me any compensation for their use.
First Name Last Name Signature
Email Phone Date Program/Year of Graduation
By signing above, you acknowledge that you are 18 years of age or older and have read and understand the terms of this release. The University will not sell photo/video footage to any third party.
Images are protected under copyright of Lesley University.
Lesley University
29 Everett Street, Cambridge, MA 02138
Date of Shoot Location ☐ Photography ☐ Videography For Internal Use Only