Television Broadcast Media Consent Form

Television Broadcast Media Consent Form
Please complete this form to provide consent for the use of your image, voice, or likeness in television broadcasts.
Participant's Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you the participant or a parent/guardian?
Parent/Guardian Full Name (if applicable)
First NameLast Name
Relationship to Participant (if applicable)
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Program or Event Name
Date of Recording/Broadcast
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location of Recording
Signature
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Should be Empty: