PARTICIPANT RELEASE FORM

FOR STUDENT VIDEO & FILM PRODUCTION

Programme Title

(working or provisional):

Five Cycles of Mazikki

Name/s of producer/s: Tara Peak

This section to be completed & signed by interviewee/participant:

Name: Tara Peak (print) I agree to participate in the production named above. The nature and composition of the programme have been explained to me and I hereby give my consent for the voice and/or picture recordings made of me, and my contribution, to be edited and used at the discretion of the Producers. Signed: T P PEAK Contact Address: 43 Preston Avenue, Wymondham, Norfolk Telephone: 01953 798730 Date: 6/05/2013