Filming/Photography Release Form

As a participant/guest of XTremBol, you will be photographed and/or videotaped. You hereby grant XTremBol permission to use, display, distribute, copy, reproduce, assign, transfer, license and/or broadcast, in complete or partial form, on CD-ROM, videocassette, broadcast, cablecast, laserdisc, multimedia and any other media format now or hereafter known, your image, voice, pronouncements, likeness, and your name and any biographical material. Name of production participant: ______________________________________ XTremBol ID ____________________________________________________ Contribution (your role in the production): ________________________________ Participating Team (if applicable): ________________________________ Team Representative (if applicable): ________________________________ Address of project participant: ________________________________ Name of parent / guardian (if applicable): ________________________________ Contact telephone number: ___________________________________ Declaration: I understand that in signing this license I am giving consent that any film or other images produced of me through this production can be reproduced or screened in a public setting, on broadcast media, in print, on the web at the discretion of the film maker. I hereby grant to XTremBol and to its employees, agents and assigns the right to photograph and/or film me and use the photo, film and or other digital reproduction of me or other reproduction of my physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the Internet. (To be signed by Parent or Guardian if under 18 years old) Signed: Name: Date:

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