PHOTO AND VIDEO RELEASE FORM

The University of Texas at Brownsville
Office of Marketing and Communication • Commissary Building • 956-882-8224 • Fax: 956-882-3869
PHOTO AND VIDEO RELEASE FORM
I hereby grant to The University of Texas at Brownsville and its representatives, employees, agents and assigns the
irrevocable and unrestricted right to use, reproduce and publish photographs and/or videos of me, including my
image and likeness as depicted therein, which are identified in Appendix A* hereto, for editorial, trade, advertising
or any other purpose and in any manner and medium, and to alter the same without restriction and to copyright the
same. I hereby release The University of Texas at Brownsville and its trustees, officers, employees, agents, legal
representatives and assigns from any and all claims, actions and liability relating to its use of said photographs
and/or videos.
IN WITNESS WHEREOF, the undersigned, intending to be legally bound hereby sets their hand and seal the date
written below.
Name (Print) ____________________________________________________________________________________________________________________________________ Date __________________________________________________
Signature __________________________________________________________________________________________________________________________________________ Phone ______________________________________________
Address _________________________________________________________________________________________________________________________________________________________________________________________________________
City ______________________________________________________________________________________________________ State ___________________________________ ZIP code __________________________________________
If under 18, signature of parent/guardian ___________________________________________________________________________________________________________________________________________
Parent/guardian name (print) _________________________________________________________________________________________________________________________________________________________________
*Appendix A is simply a brief description of the photographs and/or videos in question. If the release is for an
upcoming event, or several events, your Appendix A might read something like this:
Photographs taken at 4-H Round-up in Cameron County, June 2008.
Appendix A ______________________________________________________________________________________________________________________________________________________________________________________
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