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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: