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Video Release Form

 Page A Day Math Photo/Video Release Form
(Please PRINT THIS PAGE and email it to janice@pageadaymath)

I, _____________________________________________(print your name), grant permission to PAGE A DAY MATH and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release PAGE A DAY MATH and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

I acknowledge that I am [   ] over the age of 18

Name:________________________________________________________

Signature: _______________________________________Date: _________

Address: ______________________________________________________

                ______________________________________________________