CHABOT COLLEGE TELEVISION

25555 Hesperian Blvd. Hayward, CA  94545

CONSENT AND RELEASE

 PLEASE PRINT OUT THIS FORM FILL IT OUT AND THEN BRING IT TO KCTH 27 CHABOT COLLEGE TV

By signing this form, I give my consent to Chabot College Television to use and Reproduce my name, voice and picture in  a program to be aired by on a not for profit cable television station.  I also agree to the use of my name, voice and picture in program publicity materials, for non-broadcast showings to private groups and for educational television production.

 

By signing this form, I also release Chabot College Television, Chabot College and Chabot – Las Positias Community College District from any claim I might have against it because of the use of my name, voice and picture including for example, any claim based on defamation, slander, libel or invasion of privacy, I also release Chabot College Television.

 

I also release Chabot College Television’s affiliations and any stations or networks making use of my name, voice and picture as well as the director, officers, employees or agents of any of the above organizations.

 

I acknowledge that I will receive no money from Chabot College Television for giving this consent and release.  I am an adult (18 years of age or older).  I have read and understand this form

 

DATE:  ________/_______/_______

 

PRINT NAME of TALENT or CHILD: _______________________________________________________________________

 

PRINT NAME OF TALENT/PARENT  OR GUARDIAN: _______________________

 

SIGNATURE of Parent or Guardian or Talent: _________________________________

 

STREET ADDRESS:_____________________________________________________

 

CITY_________________________________STATE___________ZIP_____________

 

SIGNATURE of WITNESS:__________________________________________

OFFICE USE ONLY

 TITLE OF SHOW:_____________________________________________

 

SHOW PRODUCER:

DATE SHOW WILL AIR:   ____________/_____________/_____________