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Baldwin-Wallace College

BuzzTV

Producer: _________________________________

Program:  BuzzTV

Segment:  _________________________________

I grant Baldwin-Wallace College 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 College 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______________________