BuzzTV

Baldwin Wallace University

BuzzTV

Producer: _________________________________

Program:  BuzzTV

Segment:  _________________________________

I grant Baldwin Wallace University the right to use my full name, likeness, voice, biographical information and any materials provided by me for the use of the program listed above.

I understand that Baldwin Wallace University and the producer will hold the copyright on the recording of my full name, likeness, voice, and biographical information and any materials provided by me, and I understand that this recording may be retained for file footage or used for the purpose of publicity or promotion for BuzzTV.

Name_________________________________            Date _________

Signature_____________________________

Address _______________________________________________________

              _______________________________________________________

              _______________________________________________________

Phone______________________