The above-named guest does hereby consent to the recording and distribution and reproduction of the guests voice and performance as part of the media program entitled "The pACT Networks and Community Pay it Forward Companies" herein referred to as the program. This is to confirm that the undersigned has agreed to be interviewed or otherwise participate in the program, a production of the pACT Channel.
As a condition of the publication/ broadcast there shall be no monetary compensation, the pACT Channel requests the non-exclusive worldwide rights to reproduce, distribute, and sell your oral and/ or your audio and video presentation, in whole or in part, in any media, as part of the Program published under the auspices of the pACT channel and to license these rights to others, in perpetuity. The pACT channel shall have the right to edit and/ or transcribe your presentation.
You are also granting the pACT Channel to the right to use your name, biography, and likeness in connection with the Program.

I, print name , agree to the above terms on the date of date .