Yes, here is a template. You can copy-paste it and adapt it to your needs.
Authorization to use the image
[Name of your company]
I, [_________________________________]
Born on (date): [________________________]
at [________________________________________________]
Nationality: [________________________________]
Contact (phone/email): [______________________________ ]
Acting on my own behalf,
Authorizes the company [Name of your company],
located at ___________________________________, to reproduce, exploit, diffuse my image use on the production ____(write details)_______________________ on the date __________________________________ for the needs of __________(write details)__________________________________________.
This authorization carries the possibility for the company [Name of your company] to bring to my image and to my service all modifications, adaptations or deletions that it will judge useful, in the respect of my original remarks.
In particular, [Name of your company] may use my image, publish it, reproduce it, adapt it or modifier, alone or in combination with other materials, by all means, methods or techniques currently known or to come.
This authorization is valid:
Duration: [for the entire duration of the exploitation of the video].
For an exploitation on the following territories: [world, all countries, others...].
For a diffusion of the photo/video content and its derivatives on all material and immaterial supports, in all formats known or unknown to date, and in particular, without this list being exhaustive: paper media (prints of the photographs), catalogs and various editions, CDROM / DVDROM and other digital media known and unknown to date, any audiovisual medium, in particular cinema, TV and by all means inherent to this mode of communication, the Internet (including Intranet, Extranet, Blogs, social networks), all reception vectors (smartphones, tablets, etc.), press media (television commercials, cinema commercials), internal communication supports, promotional supports (POS, ILV, affichage campaigns in all places, all sizes and on all supports (urban, airports, train stations, public transport, etc.)), supports intended for sale (merchandising products: postcards, posters, T-shirts, etc.), right of integration in another work/multimedia work.
The company [Name of your company] expressly refrains from using the images and recordings in a way that may infringe on my privacy or reputation, my dignity or the integrity of my person.
I guarantee not to be bound by any agreement with a third party, of any nature whatsoever, having the purpose or effect of limiting or preventing the implementation of this authorization.
The present authorization to use my image rights is granted [free of charge / paid].
Done at (place)_______________, on the (date) ______________
Signature