Release Form for Media Recording

purposes of their AS Media Studies

l, the undersigned, do hereby consent and agree that, for the
the rigttt to take
coursework pioductions, Charlotte Barraclough and Faye Higgins,trave
photoqraphs, viceotape, or digital recordings ol me (beginning on February 11'n.2011 and ending
il#;ili+frlor i1 ano to-rs" these in any and all media, now or hereafter known. I further
text or commentary
consent that my name'and identiV may be revealed therein or by descriptive
(e.9. within lilm credits).
School, its
ldo hereby release to bharlotte Barraclough and Faye Higgins and llkley Grammar publicly
print and electronic form or
agents, anO emptoyees all rights to exhibitlhis work in
may have to
piivateiy and to'marXet and Jellcopies. lwaive any rights, claims, or interest I
control ihe use of my identity or likeness in whatever media used'
I understand that there will be no financial or other remuneration
for recording me, either for initial
or subsequent transmission or playback'
I also understand that llkley Grammar School is not responsible
for any expense or liability
expenses due to any
incurred as a result of my farticipation in this recording, including medical
sickness or injury incurred as a result.
the foregoing statement'
I represent tnit iam at least 1B years of age, have read and understand
years of age, please ensure that your
and am competent to execute tlris agreemLnt. lf under 18
parent or guardian also signs.

Name:SoPhie Dixon

Date: Address [oPtional]:

9lelQott.
Phone [oPtional]:

Signature of parent/guardian (if aged under 18):