Name:       _____________________

Address:    _____________________


Telephone: _____________________

Age:          _______ 

For good and valuable consideration, the sufficiency and receipt of which I acknowledge, I hereby grant to _______________________ the right to photograph and record me in any manner and to use such recordings (including, without limitation, my name, image, likeness and voice) in and in connection with the motion picture currently entitled "MovieTitle" ("Picture") and all advertising and publicity therefor, and the right to exploit the same, worldwide, in perpetuity, in all media now known or hereafter devised. I expressly release Producer from any and all claims which I may have in connection with the use of my name, image, likeness or voice and I agree that in no event will I be entitled to seek injunctive relief against Producer or the Picture.

By signing below, I acknowledge that I have read the foregoing and agree to be bound by its contents.


By:________________________________________________       Date:________________