AUTHORIZATION AND RELEASE

Program Working Title: ____________________________________

In return for the opportunity to participate in the above named program, I hereby grant to:

______________________________________________________

cable access program producer, permission to transmit live and/or to record for later transmission my likeness and/or voice as a part of the above named cable television access program for any lawful purpose, at any time.

I also authorize the use of my name and excerpts from said program for the purpose of promoting and publicizing that program.

I waive any right that I may have to inspect or approve the finished product or the written copy that may be used in conjunction therewith, or the use to which it may be applied.

I agree to hold the program producer and any cable television company that transmits the program harmless for any liability to others arising from anything I may say or do during the program, except as set forth in a written script provided to me by the program producer.

I have read this agreement before signing and fully understand its contents.

NAME: _______________________________________________

SIGNATURE: __________________________________________

ADDRESS: ___________________________________________

CITY, STATE: __________________________________________

ZIP: _________________________________________

DATE: _______________________________________

Signature of parent or guardian if
above named person is not of legal age: _________________________