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Photography Release Form
I hereby give my consent that the photographs/video taken of me may be reproduced in advertising, publications, promotional email campaigns, websites, and other materials or media for The Pennsylvania State
University College of Agricultural Sciences.
In giving this consent, I release the photographer, The Pennsylvania State University, and the College of
Agricultural Sciences from responsibility for any violation of personal or proprietary rights I may have in
connection with this use.

Name of Model (please print)

Signature Date

Parent Signature (if model is a minor)

Date

Current Address

City

State

Zip Code

State

Zip Code

Home Address (if different from Current Address)

City

Email Address

Home Phone

Description of Photo/Video

This publication is available in alternative media on request.
Penn State is an equal opportunity, affirmative action employer, and is committed to providing employment opportunities to all qualified applicants withou