- ReleaseFormAdult

Please complete our Online Adult Photo Release

If you have sent us a photo for use in the book, on the website, sent us a video, or are going to be in the film, please complete this form and send it back to us, otherwise we cannot use what you send us. Thank you.

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Electronic and/or Press Photo/Video Release Form For “The Conversation” Book and film.

Full Name

Address

City

State

Zip Code

Age

E-Mail

Phone

Date

I, hereby consent that the photographs and/or motion picture/video film of myself may be used by Sebastian St.Troy and any publishing agency or film producer, their assigns or successors, in whatever way they desire, including television and for electronic purposes. This would include posting said photographs and/or motion picture/video film on www.theHIVconversation.com, or on the web site of any supporting agency. Furthermore, I hereby consent that such photographs, film, video recordings, videotapes and all other visual mediums, may be used free and clear of any claim whatsoever on my part.

Please varify that by typing your name above and checking this box that you acknowledge that this will serve as your legal signature.Yes, this is my legal signature.