Name *

First Name

Last Name

Date *

MM

DD

YYYY

Photo Release *

I hereby grant Derek L'Heureux Photography permission to use my likeness in a photograph in any and all of its publications, including, but not limited to, printed and digital publications. I acknowledge that my participation is voluntary, and I will receive no financial compensation. I hereby irrevocably authorize Derek L'Heureux to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Derek L'Heureux's programs or for any other related, lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge Derek L'Heureux from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I agree