Head-shot Information & Agreement Name* First Last Email* Date* Date Format: MM slash DD slash YYYY Pay what you can... or leave a tip This service is being offered free of charge to you and is sponsored by ConnectWork on Main. If you are able to, please consider throwing some money in the virtual jar to say thank you to the photographer. Anything collected will be given directly to the photographer. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Check this box if you would like us to send a photo of you to the Butler Eagle’s archives for their future use. Consent* I agree to the terms and conditions.As part of the SERVICE(S) you receive from Those in Motion & ConnectWork on Main (the “COMPANIES”) would like to add video and or photographic examples to its client portfolio (the “PORTFOLIO”) for any reasonable personal and or commercial purpose now and in the future. I give the COMPANIES my full and explicit permission to: - Take a reasonable amount of pictures to show accurate before and after results as part of the SERVICE that I received from the COMPANY. - Use the photographs and or videos taken, in any • reasonable matter, • in whole or in part, • modified or altered, • either by themselves or in conjunction with other photographs, • in any medium or form of distribution, • and for any purposes whatsoever including without limitation, • all promotional and advertising uses, non-commercial or commercial display, broadcast, exhibition of the final protection, and other trade purposes. - Display pictures and or video worldwide (social media has made everything worldwide) I voluntarily waive the right to inspect and or approve the final product or copy, I agree that the photographs, reproductions, and or negatives shall constitute the COMPANY’S sole property, and that it has the sole right to dispose of the photographs, reproductions, and or negatives in any way that it decides. I agree to release and discharge the COMPANIES and its respective representatives, licensees, successors and assigns, and its clients, from any and all claims, actions, and demands arising out of or in connection with the use of said photographs, including, without limitation, any and all claims for invasion of privacy. I am over age 18 and have the legal capacity to sign this photo release.