Public Screening License/Appearance Agreement
Contact Information
Contact Name
*
First Name
Last Name
Title
Host Organization Name
*
Hosting Party
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Event Information
Describe your proposed event
Event Date
*
-
Month
-
Day
Year
Date
Start Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event Location
*
Venue Name
Street Address
City
State / Province
Postal / Zip Code
Venue Setting
Indoor
Outdoor
Anticipated Number of Attendees
*
Will there be an admissions charge
Yes
No
What will be the per person admissions charge?
Will there be a 2nd screening?
Yes
No
Date for 2nd Screening
-
Month
-
Day
Year
Date
Start Time for 2nd Screening
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End Time for 2nd Screening
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Will there be a 3rd screening?
Yes
No
Date for 3rd Screening
-
Month
-
Day
Year
Date
Start Time for 3rd Screening
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End Time for 3rd Screening
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Will there be more screenings?
Yes
No
Identify the dates and times for each additional Screening
Appearance Request
Would you like members of the Production Team to attend your event for a Q&A Session?
*
Yes
No
Production Team members requested at the event.
*
Joyce Fitzpatrick
Brian Shackleford
Rebecca Robinson
Dr. Earle Robinson, Jr. (Indianapolis Only)
Please indicate your agreement to the personal appearance requirements
*
Host will provide, at no cost to The Color of Medicine, LLC or the production team members, all airfares, hotel accommodations and lunch (events that do not require an overnight stay) or lunch/dinner (events requiring overnight stay), as well as local ground transportation as necessary to and from the airport to hotel and to the Event venue. Host understands that the lodging, travel and food costs are in addition to the required honorarium for each production team member's appearance.
Host will forward a final travel itinerary to The Color of Medicine, LLC or the production team members no less than ten (10) business days before The Event. The itinerary shall be forwarded to info@thecolorofmedicine.com. Any and all changes will be communicated via info@thecolorocmedicine.com as soon as they occur.
Back
Next
My Products
Select all that apply to your request
prev
next
( X )
The Color of Medicine - Screening
$
1,000.00
Number of Screenings
1
2
3
4
5
Item subtotal:
$
0.00
Honorarium - Joyce Fitzpatrick (Executive Producer, Co-Director)
$
500.00
Honorarium - Brian Shackleford (Producer, Co-Director)
$
500.00
Honorarium - Rebecca Robinson-Williams (Producer)
$
500.00
Honorarium - Dr. Earle Robinson (Indianapolis Only)
$
500.00
Enter coupon
Apply
Total
$
0.00
NOTES
Terms & Conditions
Click on the link to access the terms & conditions.
Submit
Should be Empty: