Free model release form 33
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RELEASE
I acknowledge that a photograph was taken of me on 12-14 May 2010 at The Foresight Centre,
Liverpool, UK by a photographer acting on behalf of
The University of Western Ontario.
I release all my rights in and consent to the use of this photo for all legal purposes (including,
without limitation, advertising, display, editorial, packaging, promotion, television, etc.) by the
University of Western Ontario.
Name:

________________________________________________________

Address:

________________________________________________________
________________________________________________________

Phone number ________________________________________________________
E-mail

________________________________________________________

Signed:

________________________________________________________

Date:

________________________________

The personal information on this form is collected under the authority of the University of Western Ontario
Act, 1982, as amended. The contact informa