Film Dialogue Clip Usage Consent Form
Please complete this form to provide your consent for the usage of your film dialogue clip.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Role in the Project
*
Please Select
Actor/Actress
Writer
Director
Producer
Other
Project or Film Title
*
Description of the Dialogue Clip (scene, context, or lines)
*
Intended Use of the Clip
*
Please Select
Promotional Material
Festival Submission
Online Publication
Educational Use
Other
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit Consent
Submit Consent
Should be Empty: