Media Consent Form

First Name

Last Name

Age

Date of Birth

Gender

Phone

Address

Html

Model Authorization, Release and Consent

Can we use your name?

Full Name

First Name

Nickname

Anonymous

How can we use images of you?

I authorize and grant Kasia Haroldsen to take my photos regarding my experiences with her.

I grant, Kasia Haroldsen to use my photos on Facebook, Twitter, Instagram, and other social media platform.

I allow Kasia Haroldsen to edit, alter, copy, or distribute the photos for social media advertising and marketing.

I agree that the photos belong to Kasia Haroldsen.

I understand that I will not receive any monetary compensation.

Signature

Signed Date

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