I hereby grant ______, a division of ______, Inc., its affiliates, licensees, and each of their respective officers, directors, employees and agents (for purposes of this agreement, "______") the irrevocable right to:
1. Use, edit and re-use the acts, pictures, poses, performances, statements and sound materials of myself that are contained in the material that is being recorded by ______in connection with the "______" program (the "Submitted Material"), throughout the world and in perpetuity, on standard and non-standard television, home video, print and electronic media (including, without limitation, the Internet or any other on-line medium), and in any other means of distribution, publication or exhibition, whether now known or hereinafter created, as part of any ______production or publication, including, without limitation, on the ______website and within the television program entitled "______"; and
2. Use my name, voice, likeness, statements, actions and biographical data in connection with the production, publicity, advertising, promotion, exhibition or other exploitation or use of any of the Submitted Material or any production incorporating the Submitted Material.
I hereby release and hold ______harmless from any claims or liabilities of any kind arising out of or in connection with the making or the use of the Submitted Material and the use of my name, likeness or biography. I understand and agree that I will not receive any compensation of any kind in connection with any use of the Submitted Material or any other rights granted by me hereunder and that ______is relying on the rights granted herein. I also represent that I am eighteen (18) years of age or older (or if I am under eighteen (18) years of age my legal guardian has signed below in order to consent to all of the foregoing).
AGREED TO AND ACCEPTED:
______/ ______
Name / Signature
______/ ______
Date / Signature of Parent or Guardian
(if releasee is a minor)