Authorization & Release

Authorization & Release
Program Title*
Program Producer*
I understand that my participation in the above program may be produced and recorded for duplication and distribution throughout the United States and abroad.

I hereby agree and consent that this program material may be edited and used in whole or in part for cablecasting, broadcasting or webcasting purposes, for audio and/or visual, cassette, and closed circuit exhibition purposes, and all other purposes in any matter or media. I consent to publication of the program transcript in whole or in part and to the use of my name, likeness, and voice in connection with program publicity and for institutional promotional purposes. I also release the producer from any privacy, defamation or other claims I may have arising out of the recording, reproduction, cablecasting, broadcasting, exhibition, publication, or other distribution and promotion of this program material.
Check here if..

the following participant is a minor and will have a parent/guardian co-sign this document.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I * of the minor who has signed the above talent release, hereby agree that we shall both be bound thereby.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: