Actor-Participant Release Form
Vertigo Documentary
Production Intro:
I confirm that this institution or organization has the right to record me in a video or audio-only.
I allow this institution or organization to edit, duplicate, sell, distribute, and copyright the videos, audios, or photos taken during my session. It can be used in films, radio, commercials, billboards, and other forms for advertisements.
I understand that these materials (videos and audios) will become the property of this institution or organization.
I commit that I will follow the schedule provided for recording or taping.
I commit that I will do my best in this project and give my 100% attention.
I confirm that I am over 18 years of age and capable of entering a contract. If you're under 18, please ask your parent/guardian to sign up for a separate release form.
I confirm that all information listed in this form is true and accurate.
Information about the Actor-Participant
Vertigo Documentary
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many years have you experienced Vertigo?
Number of Years
Vertigo - Frequency of Symptoms
0
1
2
3
4
Never
All the time
0 is Never, 4 is All the time
One sentence to describe your vertigo experience.
Tagline of your experience with Vertigo
How were you diagnosed with Vertigo?
Diagnosed - Doctor
Diagnosed - Holistic
Self-Diagnosed
Not Sure/ Don't Know
Select One Option
Camera Comfortability
1
2
3
4
5
Not at all
Very
1 is Not at all, 5 is Very
Interested in helping the production behind the scenes? Additional agreements required.
Yes, I'm interested in helping
No, I'm not interested in helping
Acknowledgment
Actor-Participants's Signature
Date
-
Month
-
Day
Year
Date
Submit
Print Form
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