Media Release Form

I, the undersigned, hereby authorize Fidelity Bank to photograph me, take motionpictures of me, take video footage of me, and/or make electronic sound recordings of me(herein referred to as photographic or electronic reproductions).

I authorize the use of any such photographic, audio, video, or electronic reproductions of my image, appearance, likeness, voice, or actions to be used at Fidelity Bank's discretion in any medium, including, without limitation, company-related publications and websites, and social media. I grant Fidelity Bank the unrestricted right, worldwide and in perpetuity, to make, copyright, use, re-use, or publish recordings in which I may be included, in whole or in part, and waive any right to inspect or approve the finished medium. (I understand that I may be identifiable in such medium).

I understand that I waive the right of approval for the final form for which these imagesand recordings are used and that I will not receive financial compensation for the use ofthe materials. I also agree to hold Fidelity Bank harmless for liability of any nature.

  • OK Name is required
  • Optional OK Business Name is required
  • Optional OK Your Title is required
  • Optional OK Social Media Handles is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
  • OK Phone is required

  • I am submitting this form as an individual

    OK I am submitting this form as an individual is required

  • I am signing this form as a representative of a group, and have full authority to grant release for this group

    OK I am signing this form as a representative of a group, and have full authority to grant release for this group is required
  • OK Name of group is required

  • I am over the age of eighteen years (If you are a parent giving consent for a minor, please choose No to proceed to Parental Consent section.)

    OK I am over the age of eighteen years (If you are a parent giving consent for a minor, please choose No to proceed to Parental Consent section.) is required

Parental Consent

  • OK Name of Applicant’s Parent/Guardian is required
  • OK Address of Applicant's Parent/Guardian is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
  • OK Phone is required
    OK I certify that I am the parent or guardian of the individual above, a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this Media Release. is required
  • OK is required