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Indiana University Bloomington

Undergraduate Department


* Required Fields
Kelley Photo Release Form

If you are younger than 18, you must have a parent or family member present while completing the Photo Release Form.

I hereby grant to Indiana University the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of university related photographs or videotaped images of the undersigned student for use in connection with the activities of the university or for promoting, publicizing or explaining the school or its activities.  This grant includes, without limitation, the right to publish such images in the university’s student newspaper, alumni/ae magazine, on the university’s Web site, and public relations/promotional materials, such as marketing and admissions publications, advertisements, fund-raising materials and any other university-related publication.  These images may appear in any of the wide variety of formats and media now available to the school and that may be available in the future, including but not limited to print, broadcast, videotape, CD-ROM and electronic/online media.  All photos taken are without compensation to me (the undersigned).  All electronic or non-electronic negatives, positives, and prints are owned by the university.

*Program Name

Participant Age

*Birth Date: 

Participant Signature

I hereby acknowledge that I have read and understand the terms of this release.

Participant Signature:       E-Mail:
    Date: 5/24/2015
Witnessed By:  

Parent/Guardian Signature for Minors

If you are under 18 years of age, please have your parent or family member complete this section.
I hereby acknowledge that I have read and understand the terms of this release for the above named minor.

Parent/Guardian Signature:       E-Mail:  
    Date: 5/24/2015
Witnessed By: