This is a typical release form used to secure permission to use an individual’s likeness with or without identification.
From Public Relations Writing & Media Techniques (Fourth Edition) by Dennis Wilcox.
Sample Photo Release Form
Organization Name Address
City, State, Zip
Permission to Use Photograph Subject: Location:
I grant to [insert organization], its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize [insert organization], its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that [insert organization] may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.