Photo Release Form

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Photo Release Form

Photo Release Form

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First name

Last name

Photographer name

Consent and Release

I grant to Workers’ Safety and Compensation Board (WSCB) and the photographer, the exclusive, irrevocable, and royalty-free right in perpetuity to make, copy and use any visual recordings of myself in any format, digital or analog, without restriction, in any form of media, for promotional purposes including advertising. I hereby release the above-named, and their elected officials, officers, employees, successors, assigns and licensees, from any claim I may have against them directly or indirectly in relation to their making, copying, or use of such recordings of me.

This Photo Release is binding on me, my successors, assigns, and licensees. I have read this release and its contents.

Signed

Date

Consent for a minor, under 19 years of age)

I am the parent or guardian of the minor named above and I have the legal authority to execute this release. I have read and agree to the above release.

Parent or guardian name

Phone number

Date

This information is being collected under the authority of the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at 401 Strickland Street, Whitehorse, YT Y1A 5N8 or at (867)667-5645 or 1-800-661-0443.