Model/Media Release Photo/Video/Media Date(Required) MM slash DD slash YYYY Project/Class(Required)Consent(Required) I hereby give permission to Eastern Washington University to use my name and photographic likeness, artwork, profile, image and or story in all forms and media for advertising, trade, and any other lawful purposes including release to a third party social networking website. I understand the circulation of the materials may be worldwide and that there will be no compensation to me for this use.Your Name(Required) First Last Date(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) If under 18 years of age:Consent I hereby assign and grant to Eastern Washington University the right and permission to use and publish the photographic or electronic reproductions of my child. I agree to the terms of distribution as set printed above.Parent/Guardian's Name First Last Date MM slash DD slash YYYY Δ