Western Illinois University Model Release Form
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Western Illinois University
I, _______________________________, do hereby give Western Illinois University its assigns, licensees, and legal
representatives the irrevocable right to use my name (or any fictional name), picture, portrait, photograph, and/or video
image in all forms and media (including the Internet) by Western Illinois University, and I waive any right to inspect or
approve the finished version(s), including written copy that may be created in connection therewith.
Model Signature ___________________________________________________
Local Address ___________________________________________________
E-mail Address ___________________________________________________
Year in School ___________________________________________________
If under 18, parent/guardian signature required:
Have you ever been convicted of a felony, misdemeanor or ordinance v