Very strange "permission" form to use my name in a story

For good and valuable consideration, the receipt of which is hereby 

acknowledged, I, ___________________________ (“Subject”), hereby irrevocably grant 

to XXXXXXXXXXXX, and YYYYYYYYYYYYYY , the absolute right 

and permission to publish my name and/or photograph or likeness and/or statements 

(either in part or in their entirety) in: (a) the publication, ZZZZZZZZZZZZZZ, that ,

 (including all print and digital versions), (b) reprints of the article, including excerpts thereof, 

in which Subject’s name and/or photograph or likeness 

and/or statements originally appeared (including all print or digital versions) and (c) 

promotional materials relating to ZZZZ, YYYY, XXXXX, in any and all media. 

In the event this Consent & Release cannot by signed by the Subject, the undersigned represents that 

he/she is fully authorized by Subject to grant the rights herein.  

Subject agrees that electronic signatures shall have the same force and effect as original signatures. 

________________________________________________ 

Print Name 

________________________________________________ 

Signature 

________________________________________________ 

Address 

________________________________________________ 

City/State/Zip Code 

________________________________________________ 

Telephone 

________________________________________________ 

Email 

________________________________________________ 

Date 

he/she is fully authorized by Subject to grant the rights herein.