STUDENT FILM/VIDEO/STILL PHOTOGRAPHY

WARRANT

Date: 01/28/2009

To: UCLA Events Office

168 Kerckhoff Hall
721306

I Adrien Husson warrant that my film location shoot on 02/01/2009

NAME OF STUDENT DATE
is part of a class or University sponsored program. The class/program that I am enrolled in is
________________________
FTV 400/151 in which ____________________________
Belinda Starkie is my
CLASS / PROGRAM NAME OF ADVISOR / PRPFESSOR
Advisor/Professor. I will notify the Events Office of my intention to shoot film/video/still
photography and will obtain a valid permit in accordance with published guidelines. I will secure
confirmation from the facility manager of each location and will submit this to the Events Office
as part of my permit request.

I also acknowledge that if I am unable to secure a Faculty or Staff to be present at the film shoot,
the Events Office may require a Location Manager at a cost of $50.00 per hour for all hours of
occupation of the locations listed below.

Locations: Botanic Garden

Synopsis: A little girl spends a day at the park.

Signed:
STUDENT SIGNATURE Advisor / Professor SIGNATURE

Adrien Husson
PRINTED NAME PRINTED NAME

558, Glenrock Ave

ADDRESS CAMPUS ADDRESS

Los Angeles, CA 90024

ahusson@ucla.edu
EMAIL CAMPUS EMAIL

310-592-8721
TELEPHONE CAMPUS TELEPHONE

Student Warrant rev10.08