Live Event Broadcast Release Form
Please complete this form to authorize the use of your image, voice, and likeness in the live broadcast of this event.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Event Name
*
Event Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Event Location
*
Your Role at the Event (e.g., speaker, performer, attendee)
*
Organization or Production Company Name
Are you 18 years of age or older?
*
Yes
No (If under 18, parent/guardian must complete the form)
If under 18, Parent/Guardian Full Name
First Name
Last Name
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments or Special Instructions (optional)
Signature (Participant or Parent/Guardian if under 18)
*
Submit Release
Submit Release
Should be Empty: