Form Center

2. 
3. 
   
   
   CONTRA COSTA COUNTY
   OFFICE OF COMMUNICATION AND MEDIA
   
   RELEASE FOR USE OF IMAGE OR LIKENESS
5. Contra Costa County features video and media across a wide variety of platforms . By filling out the form below, you give the County of Contra Costa (“County”) the absolute right and permission to the unlimited use of your image and likeness in photographic, video, film, slide, or any other electronic or printed formats as follows:
7. First Name*
8. Last Name*
10. 1.*

    I understand and agree that the County may use my image or likeness in its educational or promotional materials, publicity efforts, or for any other lawful purpose.

    1. I understand and agree
12. 2.*

    2. I understand and agree that these materials will become the property of the County and will not be returned;

    1. I understand and agree
14. 3.*

    3. I understand and agree that the County shall have the right to use my image or likeness in any display, publication, print ad, direct-mail piece, or electronic media, including, but not limited to, video, online, email, or television;

    1. I understand and agree
16. 4.*

    4. I understand and agree that the County’s use of my image and likeness will be without any compensation to me or my heirs or assigns.

    1. I understand and agree
18. 5.*

    I authorize the County to edit, alter, copy, exhibit, publish or distribute my image or likeness for these purposes.

    1. I understand and agree
20. 6.*

    I waive the right to inspect or approve the finished product in which my image or likeness appears.

    1. I understand and agree
22. 7.*

    7. I release and hold harmless the County, the photographer, their officers, employees, agents, and designees from any liability, claims, demands, causes of action, or attorneys fees regarding the use of my image or likeness, including for violation of any personal or proprietary right I may have in connection with such use.

    1. I understand and agree
24. I am 18 years of age or older, have read and understand this release, and agree to this release voluntarily.*

    1. True
    2. False
26. Department*
28. Work Address*
30. Address2
32. City*
33. Zip*
35. Work Phone*
36. Date
    Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field