Release Form Agreement

Release

The undersigned agrees to release the rights to the photos he/she is shown in. The person requesting this release form can do with what he/she wishes with the pictures. You agree that you are over the age of 18 at the time the pictures were taken.

Confidentiality

We will keep all of your records and information confident unless by court order we have to release the records.

Please (print legibly) and fill out all of the information below. Please send with this proof of your age with this form.

Who are you signing this release for (the name of the person): __________________________________

Full Name: ________________________________________________________

(First) (Last) (Middle)

SSN#: __________________________________________________________________

Address: ___________________________________________________________

City: __________________________ State/Providence: ____________________

Zip/Mailing Code: ________________ Country: __________________________

Telephone number (including are/country code): ___________________________

Age: ______ Date of Birth: _______________

Current e-mail address: _______________________________________________

Please understand that by signing this agreement you agree to all of the terms and conditions set forth in the entire Agreement. Please accompany this Agreement with a current/valid photo ID.

Signature: ____________________________________ Date: _______________

I agree to all of the terms set forth in this Agreement.

Pease send the completed form to the address below:

Triple sSs Publishing

P. O. Box 1075

Lancaster, OH 43130