Internet Web and Print Model Release Form

Please Read, Sign and make photo copy of ID and Send To:

 North Coast Web Design

In consideration of my engagement as a internet web and print model, and for consideration herein acknowledged as received, I hereby grant to ("Kevin Gumina, North Coast Web Design or"), his/her heirs, legal representatives and assigns, those for whom Kevin Gumina/North Coast Web Design, is acting, and those acting with his/her authority, and permission, the irrevocable and unrestricted right and permission to; Copyright, in his/her own name or otherwise, and use, re-use, publish, and re-publish photographic portraits, pictures and video of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his/her studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any printed matter or internet use, such as websites related to North Coast Web Design and Nexxxt Design in conjunction therewith

I hereby waive any right to inspect or approve any finished product (excluding My Website) or products and the advertising of or other matter that may be used in connection therewith or the use to which it may be applied. I understand that I can inspect my website before open to general public, I also understand that I can make changes to my site before it goes live to public, once live to public I understand that fee’s will apply to make changes, I also Agree to pay in full upon receipt of the website and agree to pay any overage of web hosting that goes beyond 10 gig’s of bandwidth per month

I hereby release, discharge and agree to save harmless Kevin Gumina/North Coast Web Design,, his/her heirs, legal representatives and assigns, and all persons acting under his/her permission or authority or those for whom he/she is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

I hereby warrant that I am of legal age and have the right to contract in my own name. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. I also agree that I am not affiliated of a government office or affiliated with any law enforcement agency.

Models Real Name;                                                                          

Models Real signature;                                                                        

Models Full address;                                                                        

Witness Real name;                                                                            

Witness Real address;                                                                         

Witness Real signature;                                                                       


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