__________________________________________________________________ Producer _____________________________________________________________________Program Title
I hereby authorize you to use my name, biography, likeness, voice and performance in the above noted program.
I acknowledge that the Producer is the sole owner of all rights in and to the program and any and all recordings thereof, for all purposes.
I agree to hold you and any third parties harmless, in connection with my participation in the program, against any liability, loss or damage caused by or arising from any use of my appearance on the program, of any utterance made by me, or material furnished by me in connection with my participation.
Name (Printed) ________________________________________________________________
Signature _____________________________________________________________________
Address ______________________________________________________________________
Date _____/_____/_____
If under 18 years of age please see below:
I am the parent and/or legal guardian of the above minor, and I endorse this statement in his/her behalf.
Signature _____________________________
Name (Printed) _________________________