M O D E L R E L E A S E

Date: ___/___/___ Jeff Cleveland, Photographer File Reference(s):

Carmichael CA 95608

(916) 973-9105

For valuable consideration received, which I hereby acknowledge, I irrevocably grant Jeff Cleveland, and anyone Jeff Cleveland authorizes, the absolute permission and right to use, reproduce, sell and resell any and a11 portraits or pictures of me, or any in which I may appear in whole or in part, taken this day, to be used for publishing, advertising, art, trade, or any other lawful purpose whatsoever.

I hereby waive any right to inspect or approve said pictures or any captions or copy that may be used in connection with them or to approve the use which said material may be applied.

I hereby release, discharge, and agree to save Jeff Cleveland and any of Jeff Cleveland's heirs, executors, administrators, associates, and assigns from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or not, that may result from the making of said pictures or from any process used.

I am 18 years old or older: YES ____ NO ____

(If under 18, requires signature parent or guardian in bottom section)

Model’s Commercial Name: _________________________________________

Model's Name (print): _____________________________________________

Address: _________________________________________________________

State: _______ Zip: ________ Phone: ____________________

Model's Signature: _________________________________________________

Witness (Signature): ________________________________________________

--- For Any Model Under 18 Years of Age ---

I hereby certify that I am the parent or legal guardian of the above-named model, and I consent, without reservations, to all the foregoing on the behalf of the model.

Parent/Guardian Signature: ______________________________________

Witness (Signature): _________________________________ Date: ___/___/___