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 the absolute permission and right to use and reproduce 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 Jeff Cleveland’s portfolio (both print and on the internet) and for Jeff Cleveland’s self-promotional efforts.

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)

Images may also be sold or used commercially without further approval:

YES ____ NO ____

Model's Name (print): _____________________________________________

Address: __________________________________City: __________________

State: _______ Zip: ________ Phone: ____________________

Model's 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: ___/___/___