Wisconsin Model Release Form 4
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900 Wood Road, PO Box 2000
Kenosha, Wisconsin 53141-2000

Marketing and Publications Office
Telephone:
Fax:

(262) 595-2403
(262) 595-2440

MODEL RELEASE
For and in consideration of my engagement as a model by the University of Wisconsin-Parkside, hereafter
referred to as the photographer, on terms hereinafter stated, I hereby give the photographer, his or her
legal representatives and assigns, those for whom for photographer is acting, and those acting with his or
her permission, or his or her employees, the right and permission to copyright and /or use, reuse and/or
publish, and republish photographic pictures or portraits of me, or in which I may be distorted in character, or form, in conjunction with my own or a fictitious name, on reproductions thereof in color or black
and white made through any media by the photographer at his or her studio or elsewhere, for any purpose whatsoever, including the use of any printed matter in conjunction therewith.
I hereby waive any right to insp