In consideration of my engagement as a model, and for the consideration herein acknowledged as received, I hereby grant
the following rights and permissions to Robert Thivierge (“Photographer”), his heirs, legal representatives, and assigns, those for
whom Photographer is acting, and those acting with his authority and permission. They have the irrevocable, perpetual and unrestricted right
and permission to take, use, re-use, publish, and republish photographic portraits or pictures 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, or reproductions thereof in color or otherwise, made through any medium at his studios or elsewhere, and in any and all media now or
hereafter known, specifically including but not limited to print media and distribution over the internet for illustration, promotion, art, editorial,
advertising, trade, or any other purpose whatsoever. This release applies to all and only those photos originally taken by Photographer on the date specified below.
________________________________________________________ (Date) ________________________________________________________ (Print Model's Name) ________________________________________________________ (Model's Signature)