Model Release Form

USPG Model Release Form


This document concerns permission for use of images and films created for USPG purposes.

Name of subject: _________________________________________________________________

Email address:  ____________________________________________

Address: ______

Location of photograph: _______________________________________________


USPG would like to take your photograph or include you in a film for promotional purposes. These images may appear in our printed publications, on our website, or social media accounts. Please answer questions below, then sign and date the form.  Thank you.

Any image taken or information you provide will not be used for any other purposes.

Please circle your answer

  1. May USPG use your/your child’s image in printed, web and social media? Yes/No
  2. May USPG use your/your child’s image on our website? Yes/No
  3. May USPG use your/your child’s image for general publicity?   Yes/No
  4. May USPG use your/your child’s image for fund raising purposes, eg in a calendar or on a card? Yes/No
  5. I have read and understood the conditions of use. Signed by subject (plus parent/guardian if under 16; just parent/guardian if under 12) Signature(s): _______________________________________ Date: __________________
  6. _______________________________________ Date: __________________
  7. Conditions for use: We will not include personal contact details of any persons in an image on our website or in printed publications. To allow the use outlined above will require the image to be stored. Storage will be on secure servers and hard drives used and managed on behalf of USPG.