Participant's Name:
Program:
I hereby certify that I am over the age of eighteen, and that I have read,
understood, and agreed to the foregoing.
Electronic Signature:
Date:
Address/City/State/Zip:
Phone:
I hereby certify that I am not over the age of eighteen, and release my rights
to my parent or legal guardian.
is the parent or legal guardian of the above-named minor
and I endorse the above statement in his/her behalf on this date:
Parent's Address:
GENERAL AND MINOR TELEVISION AND BROADCAST RELEASE FORM
PLEASE FILL OUT ORDER FORM BELOW!
  In consideration for which is hereby acknowledged, and for the opportunity to participate in the
below-identified video program produced by VIP Video Productions, I agree that the program(s) may be
broadcast and distributed without limitation through any means and I shall not receive any
compensation for my participation.
 
 I confirm that any and all material furnished by me for this program is either my own or otherwise
authorized for such use without obligation to me or any third party.  I also agree to the use of my name,
likeness, portrait or pictures, voice and biographical material about me for educational, program or
series publicity and organizational promotional purposes.
 
 I further agree that my participation in the program confers upon me no rights to use, ownership or
copyright.  I release VIP Video Productions, its employees, agents, and assigns from all liability which
may arise from any and/or all claims by me or any third party in connection with my participation in the
program(s).
 
 It is understood that VIP Video Productions is under no obligation to broadcast the above-identified
program(s) or series.

  I confirm that by typing my name in the space provided, (electronic signature) & (parent's electronic
signature), this is binding as my personal hand written signature and holds my official release to VIP
Video Production.