Individual Release Form

Sample

Individual Release

Production NAME:______________ Shoot Location:_______________ Shoot Date:_______________

I have participated as indicated in the above program, which I understand will be produced and recorded for duplication and distribution in the United States and abroad. I agree that insofar as I am concerned this program may be edited as desired and used whole or in part for audio and/or visual media purposes, closed circuit exhibition purposes, and all other broadcast and media purposes (including internet, radio and TV stations) in perpetuity in the United States and abroad.

I consent to publication of he program transcript in whole or in part and also to the use of my name, likeness, voice and biographical material around me in connection with program publicity and for institutional promotional purposes. I expressly release the producer from any privacy, defamation or other claims I may have arising out of exhibition, broadcast or publication or promotion off this program.

Print Name: ____________________________________________ (please print clearly so we can spell your name correctly in the film.)

Signature: ____________________________________________ Address: ____________________________________________ ____________________________________________ Phone: ____________________________________________