Media Consent Form

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Media Consent Form

January 8, 2026

- Step 1 of 8

Effective Date

SECTION 1: PARTY IDENTIFICATION - Releasor (Subject) Information

Full Legal Name:

First

Last

Date of Birth:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Email Address:

Phone Number:

Releasee (Organization/Individual) Information

Full Legal Name/Organization:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Email Address:

Phone Number:

SECTION 2: MINOR CONSENT (If Subject is Under 18)

Multiple Items

Subject is 18 years of age or older
Subject is under 18 years of age

If under 18, Parent/Legal Guardian Information:

Full Legal Name of Parent/Guardian:

First

Last

Relationship to Minor:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Email Address:

Phone Number:

SECTION 3: DESCRIPTION OF MEDIA

I hereby grant permission for the capture and use of the following types of media featuring my image, voice, or likeness:

Checkboxes

Photographs (still images)
Video recordings
Audio recordings
Direct quotes or testimonials
Other (please specify):

Other details:

Context/Event Description:

Date(s) of Capture:

SECTION 4: SCOPE OF USAGE AND RIGHTS - Purpose of Use

The media may be used for the following purposes:

Social media platforms (Facebook, Instagram, LinkedIn, Twitter/X, TikTok, etc.)
Organization website and blog
Promotional videos and multimedia presentations
Print advertisements and brochures
Educational materials and training resources
Press releases and media kits
Annual reports and newsletters
Other (please specify):

Other details:

Commercial vs. Non-Commercial Rights

Non-Commercial Use Only: Media will be used solely for non-profit or internal purposes.
Commercial Use Authorized: Media may be used for profit-generating activities, including but not limited to advertising, product promotion, and sales materials.

Right to Edit

I grant the Releasee the right to edit, alter, crop, enhance, or modify the media in any manner deemed appropriate, including but not limited to color correction, cropping, digital enhancement, and incorporation into composite works.

Transfer of Rights

I grant the Releasee the right to transfer, license, or assign these rights to third-party partners, affiliates, or contractors for the purposes stated above.
I do NOT grant the right to transfer these rights to third parties.

SECTION 5: LEGAL PROTECTIONS AND COMPENSATION

Compensation Statement

I acknowledge that I will receive no monetary compensation for the use of this media.
I acknowledge that I will receive the following compensation:

I hereby waive any right to inspect or approve the finished product or any printed, digital, or electronic matter that may be used in connection with the media, as well as any right to royalties or other compensation arising from or related to the use of the media.

Release of Liability

I hereby release, discharge, and hold harmless the Releasee, its officers, employees, agents, representatives, successors, and assigns from any and all claims, demands, actions, causes of action, damages, costs, or expenses, including attorney's fees, arising out of or related to:

• Any use of the media as permitted by this consent form
• Claims of defamation, invasion of privacy, violation of right of publicity, or any other claims related to my image, voice, or likeness
• Emotional distress or any other personal injury claims
• Any distortion, alteration, or use in composite form that may occur in connection with the processing, publication, or distribution of the media

SECTION 6: PRIVACY RIGHTS AND DATA PROTECTION

In compliance with applicable privacy regulations including the General Data Protection Regulation (GDPR) and California Consumer Privacy Act (CCPA), I acknowledge the following:

Data Retention
The Releasee will retain the media and associated personal information in accordance with its data retention policy. Upon request, I may inquire about the specific retention period.

Right to Withdraw Consent
I understand that I have the right to withdraw my consent at any time by providing written notice to the Releasee at the contact information provided above. Withdrawal of consent will apply to future use only and will not affect media already distributed or published prior to the date of withdrawal.

To withdraw consent, I must:
1. Submit a written request via email or certified mail to the Releasee's contact address
2. Include my full name, date of the original consent, and specific media to which the withdrawal applies
3. Allow up to 30 business days for the Releasee to process the withdrawal request

I understand that withdrawal may not be possible for media that has already been incorporated into permanent materials, distributed to third parties under valid licenses, or used in contexts where removal is not technically feasible. Data Subject Rights
I acknowledge my rights under applicable privacy laws to:
• Access my personal data
• Request correction of inaccurate information
• Request deletion of personal data (subject to legal retention requirements)
• Object to processing in certain circumstances

SECTION 7: DURATION AND SCOPE

Duration of Consent

This consent is granted in perpetuity (indefinitely) unless withdrawn in writing.
This consent is valid for a specific period:
This consent is valid for the duration of: _________________________________________ (e.g., one academic year, the length of employment, a specific project)

Geographic Scope

Worldwide use authorized
Limited to the following geographic areas: _________________________________________

SECTION 8: ACKNOWLEDGMENT AND SIGNATURE

I have carefully read and fully understand this Media Consent and Release Form. I acknowledge that I am signing this form voluntarily and that no representations or promises have been made to me other than those contained in this document. I understand that this is a legally binding agreement.

I confirm that I am at least 18 years of age and have the legal capacity to enter into this agreement, OR that I am the parent/legal guardian of the minor named above and have the authority to grant this consent.

Media Consent

I consent to the use of photographs, video recordings, and/or audio recordings of me, taken or recorded by [Organization Name], for purposes including but not limited to marketing, training, promotional materials, websites, social media, and other communications. I understand that these materials may be edited, copied, exhibited, published, or distributed, and I waive the right to inspect or approve the finished product.

Releasor Signature - Print your full name in the fields below *

First

Last

Date

Parent/Guardian Signature (Required if subject is under 18) - Print your full name in the fields below *

First

Last

Non-Commercial USAGE Information

Date

Releasee Signature (Optional) - Print your full name in the fields below

First

Last

Title

Date

CONTACT INFORMATION FOR PRIVACY INQUIRIES

For questions regarding data privacy, consent withdrawal, or to exercise your data subject rights, please contact:

Privacy Officer/Contact Person - Vasquez Representative Name
Email - contactname@vasquezhospitality.com
Phone - (951) 555-1234

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