Fill and Sign the Release Authorization Form

Release and Authorization to Use Name in Book to be Published Release executed on _________________________________ (date) , by ______________________________________________ (Name of Releasor) of _____________________________________________________ (city, state) herein referred to as Releasor , in favor of _________________________________________ (Name of Releasee) of __________________________________________ (city, state) herein referred to as Author . Whereas, Author is writing or has written a book entitled or to be entitled ____________ ________________________________________________________________ (name of book) , hereinafter called Book ; and Whereas, said Book is or shall be autobiographical in nature; and Whereas, Author has used or desires to use Releasor’s name in said Book ; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: I. Releasor, being of lawful age, hereby expressly releases Author , his publishers, licensees, agents, successors and assigns (hereinafter jointly and severally called Releasees ) from all liability for claims and/or demands arising out of this agreement, included, but not limited to, libel, slander, invasion of privacy or any other claim based on use of the name of Releasor in said Book or in any derivative works from said Book, such as audio books, radio broadcasts, motion pictures, television productions, video productions or any other similar media (hereinafter jointly and severally called derivative works ). II. Releasor hereby authorizes Releasees to use Releasor’s name in Releasees’ discretion, and to incorporate Releasor’s name into said Book or such derivative works in Releasees’ discretion, and to use any information that Releasor has provided in any way to Releasees in connection with the preparation and/or publication of said Book and in the promotion or advertising relating to the preparation and/or publication of said Book and derivative works. III. Releasor further agrees to indemnify and save harmless Releasees from any and all claims and liability for damages, losses or expenses of any sort arising from the making or the publication of said Book or derivative works. IV. Releasor warrants and agrees that he has read and understood the contents hereof, and that he has the right and authority to execute this release and indemnification. In witness whereof, the parties have executed this Release and Authorization Agreement on the date and year first above written. __________________________________ ______________________________ Releasor Author