Milwaukee PBS

1036 N. 8th Street – 4th Floor

Milwaukee WI 53233

Agreement for Television Appearance

I authorize Milwaukee PBS (Producer) to make use of my appearance in the

10thirtysix/Kids in Crisis
(Production) being produced initially for Milwaukee PBS

I understand that I am to receive no compensation for this appearance, and that I am to

receive no compensation of any kind as a result of any recordings, re-broadcasts, or other
broadcast or non-broadcast uses of the Production. My work in the Production shall be a work
made for hire for Producer under the copyright laws of the Unites States. Producer shall have
complete ownership of the Production, including full domestic and foreign copyright, and shall
have the exclusive right and license to make such use of the Production as it wishes, including (but
not limited to) the right of performance, display, reproduction, and distribution in all media, and
the right to create, perform, display, and distribute derivative works of the Production.

I give the Producer the right to use my name, likeness, and biographical material to
publicize the Production, derivative works of the Production, and the services of the
Producer.

______ ______
Date Address

______ ______
Signature City

______
Print Name State Zip Code

______
Parent or Legal Guardian’s Signature Phone Number

If the person appearing is a minor,

Parent or Legal Guardian must ______
sign in the space provided. Email Address